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MINOR SURGERY. 



MINOR SURGERY: 




OE, 



HINTS 



ON THE 



EVEKY-DAY DUTIES OF THE SUKGEON. 



BY 



HENRY H. SMITH, M.D., 

ASSISTANT LECTURER ON CLINICAL SURGERY IN THE UNIVERSITY 

OF PENNSYLVANIA ; 

ONE OF THE SURGEONS TO THE ST. JOSEPH'S HOSPITAL ; 

LECTURER ON THE PRINCIPLES AND PRACTICE OF SURGERY IN THE 

PHILADELPHIA MEDICAL INSTITUTE, ETC. 



THIRD EDITION, WITH NUMEROUS ADDITIONS. 



3Ulustrate"& In> 347 EnflraMiifls. 



PHILADELPHIA: 

EDMOND BARRINGTON & GEORGE D. HAS WELL. 
1850. 






•s 



Entered, according to Act of Congress, in the year one 

thousand eight hundred and fifty, by 

BARRINGTON & HAS WELL, 

in the clerk's office of the District Court for the Eastern District 

of Pennsylvania. 



TO THE 



MEDICAL CLASS 

or THE 

UNIVERSITY OF PENNSYLVANIA 

the following pages 

aee respectfully inscribed 
:end, tj 
AUTHOR. 



1* 



PREFACE 

TO THE THIRD EDITION. 



In the former editions of this volume, some of the 
points referred to seemed of such simplicity, that 
considerable doubt existed in my mind as to the 
propriety of their consideration, presuming that 
every student would be familiar with their details. 
Experience, however, has demonstrated that it is in 
the very simplest matters that the young practi- 
tioner soonest hesitates, his collegiate studies in- 
structing him rather in the weightier matters of the 
law than in those of less importance. 

Believing, also, that the value of the original plan 
has been sufficiently tested by the fact, that two 
large editions of near five thousand copies have been 
rapidly exhausted, notwithstanding the publication 
of other meritorious works of a similar kind, it has 
been deemed best to adhere to the elementary cha- 
racter heretofore sustained by this volume, and to 



8 PREFACE. 

present it a third time, to those for whom it has been 
written, as especially adapted to their earliest pro- 
fessional wants. 

In the present edition I have, therefore, in nowise 
changed the former arrangement, but have simply 
revised and amended the text in accordance with the 
improvements of the day. Many new subjects of a 
similar elementary nature have, however, been added, 
in order to furnish the younger practitioners, and 
especially those who have not enjoyed the advantages 
of a residence in a hospital, with further practical 
details on matters of common occurrence. 

Pursuing the original object of furnishing "Hints 
on the Every-Day Duties of the Surgeon," the new 
matter will be found to be very briefly stated, and 
the operative directions given in as condensed a form 
as was compatible with accurate description. The 
Duties of Assistants in Operations, the Mode of con- 
ducting Etherization, the Mechanical Treatment of 
Club Feet, the Cure of Aneurism by Compression, 
the Catoptric Diagnosis of Cataract, and similar 
subjects, likely to prove of daily utility to the general 
practitioner, are among the principal additions ; their 
comprehension being aided by appropriate illustra- 
tions, as far as seemed needful. 

Within the few years that have elapsed since the 
publication of the first edition, "Minor Surgery" 



PREFACE. 9 

has gained a degree of attention that has materially 
changed the estimate of its general value ; and 
many who have found its practical importance, now 
regard it as a most valuable portion of a medical 
education. Should the present volume tend to main- 
tain this opinion, and prove useful to that portion of 
the Profession for whom it is especially intended, it 
will accomplish all that has been desired for it. 

HENRY H. SMITH. 



120 S. Ninth Street, 
Philadelphia. 



LIST OF AUTHORS. 



The following list embraces the authors consulted in connection 
with the present subject: — 

Amesbury, on Fractures. 

J. Ehea Barton, North American Journal, &c. 

Boyer, Maladies Chirurgicales. 

Bourgery, Minor Surgery, by Kissam. 

Bond, North American Medical Journal. 

Baynton, on Ulcers. 

Sir Astley Cooper, on Dislocations and Fractures. 

Samuel Cooper, Dictionary. 

Chelius, Surgery, by South and Norris. 

Coster, Manual of Operative Surgery. 

Cutler, on Bandages. 

R. Coates, Journal of Medical Sciences. 

Dorsey, Elements of Surgery. 

Dessault's Surgery, by Caldwell. 

Druit, Modern Surgery, by Sargent. 

Dupuytren, Lecons Orales. 

Ferguson, Surgery, by Norris. 

Gerdy, Bandages et Pansements. 
Gibson, Insitutes and Practice of Surgery. 

Goddard, on the Teeth. 

Jamain, Petite Chirurgie. 

Philadelphia Journal of Pharmacy. 

Lawrence on the Eye, by Hays. 

Liston, Elements of Surgery, by Gross. 

Medical Examiner, 1837-38. 

Mayor, Bandages et Appareils. 

Malgaigne, Medecine Operatoire. 

Pancoast, Operative Surgery. 

Pott, Chirurgical Works. 

Rankins Abstract. 

Sedillot, Medecine Operatoire. 

N. R. Smith, Baltimore Medical and Surgical Journal 

Thillaye, Traite des Bandages. 

Velpeau, Medecine Ope"ratoire. 

Warren, on Ether. 



CONTENTS. 



Preface to Third Edition 



PAGE 

7 



Introduction 



25 



PART FIRST. 



OF DRESSINGS AND BANDAGES. 



CHAPTER I. 








ON THE PREPARATION AND APPLICATION OF DRESSINGS. 


Dressings, Preparation and Application of 27 


Apparatus for .... 


28 


Instruments for . 






28 


Forceps 






29 


Scissors 






29 


Probes 






29 


Director 






29 


Spatula 






30 


Scalpels 






30 


Needles, &c. . 






31 


Pieces of Dressing . 






31 


Lint . 






31 


Charpie 






32 


Sponge Tent . 






34 


Cotton 




■ 


35 


Tow . 




36 


Compresses .... 






36 


Square 






37 


Triangular 






37 


Cribriform 






38 


Malteese Cross 






38 


Retractors 






39 


Perforated Compress 






40 


Graduated 






41 


Pyramidal 






41 


Adhesive Strips 






41 



14 



CONTENTS. 



Dressings, Adhesive Strips, Baynton's use 


of . 




44 


Critchett's use of in Ulcers 


47 


as applied in Epididymitis . 


48 


Isinglass Plaster 


49 


Collodion* ..... 


49 


Court Plaster .... 


50 


Poultices ..... 


51 


Plasters .... 


53 


Irrigation ..... 


54 


Rules for Dressing 


58 


CHAPTER II. 




OF THE PREPARATION AND APPLICATION OF THE BANDAGE. 


Bandaging ...... 


61 


Roller, Simple .... 






61 


Manufacture of 






62 


Single- headed . 




, 


63 


Double-headed 






63 


Bandage, rolling of 






62 


Application of 






64, 71 


Circular 






65, 69 


Oblique . 






65, 70 


Spiral 






65, 70 


Uniting . 






65 


Dividing 




. 


65 


Compressing 






66 


Expelling 




. 


66 


Retaining 






66 


Rules for making reversed turns 




. 


72 


Spiral 






74 


of Chest . 






74 


Abdomen . 






75 


Penis . 




, 


75 


Upper Extremity . 






76 


Finger .... 




77 


all the Fingers, or Gauntlet 




78 


Demi-Gauntlet 




79 


Lower Extremity . 




79 


French Spiral 






81 



CHAPTER III. 

OF THE CROSSED, OR FIGURE OF 8 BANDAGES. 

Crossed of one Eye ..... 

both Eyes • . . . . 

Angle of the Jaw .... 
Barton's for the Jaw .... 



83 
84 
85 
86 



CONTENTS. 


15 


Crossed, or Posterior 8 of the Chest 


87 


Anterior 8 .... 


89 


Of one Breast .... 


92 


both Breasts .... 


93 


Spica of Groin .... 


95 


both Groins . . 


96 


Shoulder .... 


89 


Thumb .... 


99 


Instep . . . . . 


101 


Figure of 8 of the Elbow 


98 


Figure of 8 of the Wrist 


99 


Figure of 8 of both Thighs 


100 


Knee 


. 100 


Ankle .... 


100 


Figure of 8 of Neck and Axilla 


. 91 


Bibbails's ..... 


101 



CHAPTER IV. 

OF KNOTTED BANDAGES. 

Knotted Bandage of Head 

CHAPTER V. 

OF RECURRENT BANDAGES. 

Recurrent Bandage of Head 

Double-headed roller 
Amputations 



104 



106 
107 

108 



CHAPTER VI. 

OF THE COBIPOSITION AND APPLICATION OF THE COMPOUND 
BANDAGE, OR THE BANDAGE PROPER. 

T Bandage 





. Ill 


of Head 


112 


Ear .... 


. 113 


Nose 


114 


Chest 


. 115 


Abdomen . 


115 


Triangular T of Groin . 


. 116 


Double T of Buttock 


117 


of Hand .... 


. 117 


Perforated of Hand . 


118 



CHAPTER VII. 

OF THE INVAGINATED, OR SLIT AND TAIL BANDAGES. 

Invaginated Bandages . 

for Wounds of Lips 



120 
120 



16 CONTENTS. 

Invaginated of Body ..... 121 

for Longitudinal Wounds of the Extremities 122 

for Transverse Wounds of the Extremities . 123 

WinsloVs, for Wry Neck ... 123 

Jb'rg's Apparatus . . . . . .124 

Uniting, of Transverse Wounds of Neck . . 125 

CHAPTER Vin. 

OF SLINGS. 

Slings 127 

or Bandage of Galen .... 127 
Four-tailed of Head . . . .128 

of Neck ...... 129 

of Chin 129 

of Face ...... 130 

Mask 130 

of Breast ..... 131 

CHAPTER IX. 

OF SUSPENSORIES, SHEATIIS, AND LACED BANDAGES. 

Purses or Suspensories ..... 133 

ofNose .... 133 
of Scrotum . . . .134 

Sheaths 135 

Laced or Buckled Bandages . . . .135 

for the Knee . . 135 
Gaiter . . . . . .136 

Stocking . . . . . 136 

PART SECOND. 

CHAPTER I. 

MAYOR'S HANDKERCHIEF SYSTEM. 

General Considerations . . . . .137 

Shape of Handkerchiefs . . . . 140 

CHAPTER II. 

OF THE HANDKERCHIEFS AS APPLIED TO THE HEAD. 

Handkerchiefs for Head . . . . 144 

Square Cap of Head .... 144 

Fronto-Occipital Triangle . . 144 

Occipito-Frontal .... 145 

Bi-Temporal Triangle ... 146 



CONTENTS. 



17 



Handkerehiefs, Occulo-Occipital Triangle 
Fronto-Occipito-Labialis . 
Facial Triangle 
Vertico-Mental Cravat 
Occipito-Auricular . 
Sternal Handkerchief 
Fronto-Dorsal 
Parieto-Axillaris 



146 
146 
147 
147 
147 
148 
149 
149 



CHAPTER III. 

OP THE HANDKERCHIEFS AS APPLIED TO THE TRUNK. 

Cervical Cravat . . . . . .151 

Simple Bis-Axillary Cravat .... 151 

Compound Bis-Axillary Cravat . . . .152 

Simple Bis-Axillo-Scapulary Cravat . - . 152 

Compound Bis-Axillo-Scapulary Cravat . . . 153 

Dorso-Bis- Axillaris . . . . . 154 

Triangular Cap of Breast ..... 154 

Sub-Femoral Handkerchief . . . 155 

Inter-Femoral Handkerchief .... 156 

Single Spica Handkerchief . . . . 157 

Double Spica Handkerchief . . . .157 

Suspensory, or Handkerchief to Scrotum . . 157 



CHAPTER IV. 

OF THE HANDKERCHIEFS OF THE UPPER EXTREMITIES. 

Cervico-Brachial Sling . . . . .159 

Ante-Brachial Trough ..... 159 

Triangular Cap of Shoulder . . . .161 

Triangular Cap of Amputations . . . 161 

Carpo-Olecranien Handkerchief .... 162 

Flexor of Wrist . . . . . . 162 

Carpo-Dorsal Triangle . . . . .163 



CHAPTER V. 






OF THE HANDKERCHIEFS OF THE LOWER EXTREMITIES. 




Metatarso-Malleolar Cravat 




164 


Triangular Cap of Heel . 


. 


164 


Tarso-Pelvien Cravat 




165 


Compound Metatarso-Rotular Cravat 


. 


165 


Tarso-Patella Cravat 




167 


Triangular Cap of Foot . 




167 


Tibio-Cervical Sling . 




167 


Tibial Cravat ; 


. 


169 


Barton's Handkerchief 




169 


2* 







18 



CONTENTS. 



Mayor's Hyponarthecia 
Ante-Brachial Hyponarthecia . 
Hj^ponarthecia of Lower Extremities 
Mayor's Clinical Frame 



170 
175 
177 
193 



PART THIRD. 

CHAPTER I. 

APPARATUS FOR FRACTURES. 



General Considerations 




201 


Setting Fractures .... 


• 


203 


CHAPTER II. 






FRACTURES OF BOXES OF THE HEAD AND 


TRUNK. 




Fractures of Skull .... 




208 


Nose .... 


. 


208 


Lower Jaw 




209 


Gibson's Bandage for 




209 


Barton's " 




86 


Vertebrae .... 


. 


210 


Sternum 




211 


Ribs .... 




211 


Pelvis 




211 


Clavicle .... 


. 


211 


Dessault's Apparatus for 




212 


Boyer's 




215 


Mayor's . 




216 


Fox's 




217 


Scapula 




221 


Velpeau's Bandage for 


• 


221 


CHAPTER III. 






OF FRACTURES OF THE UFPER EXTREMITY. 




Fractures, Neck of Humerus 


. 


223 


Boyer's Bandage for 


. 


223 


for Fracture of Shaft of Humerus 


224 


Pennsylvania Hospital Plan . 




225 


of the Condyles . 




225 


Physick's Apparatus for 




225 


Carved Splint 


. 


227 


Fore-arm .... 


. 


228 


Lower End of Radius 


. 


229 


Barton's Bandage for 


. 


229 


Metacarpal Bones 




230 



CONTENTS. 



19 



Fractures, Phalanges .... 

Olecranon 

Astley Cooper's Apparatus for 
Dessault's " 

Pennsylvania Hospital " 
Boyer's " 

Mayor's " 

Gerdy's " 

of Coronoid process . 



231 
231 

232 
232 
233 
234 
235 
235 
235 



CHAPTER IV. 

OF FRACTURES OF THE LOWER EXTREMITY. 

General Considerations .... 
Elevator for Treatment of 



237 
240 



CHAPTER V. 



OF FRACTURES OF THE FEMUR. 



Fractures, of Femur .... 


. 241 


Chapman's Inclined Plane . 


241 


Dupuytren's Inclined Plane 


. 241 


Coates's Extending Band 


243 


Physick's Gaiter 


. 244 


Coates's Perineal Band 


245 


Junct-Bags 


. 246 


Splint Cloth . 


248 


Scultet's Bandage 


. 248 


Eighteen-Tailed Bandage 


249 


Splints, Dessault's 


. 249 


Physick's 


250 


Boyer's . 


. 253 


Hartshorne's 


255 


Amesbury's 


. 256 


Gibson's Hagedorn . 


260 


Gibson's Simple Inclined Plane . 


. 262 


Nathan R. Smith's Splints . 


263 


CHAPTER VI. 




OF FRACTURES OF THE PATELLA. 




Fractures, of Patella .... 


. 265 


Dessault's Apparatus for . 


265 


Dorsey's " . 


. 266 


Mayor's " 


267 


Gerdy's " 


. 267 



20 CONTENTS. 

CHAPTER VII. 

OF FRACTURES OF THE LEG. 

Fractures, of Leg ..... 269 

Hospital Fracture-Box . . .269 

Barton's Bran Dressing . . . 271 

Hutchinson's Splints . . . 272 

Amesbury's Apparatus for . . 274 
Dupuy tren's Apparatus for Fracture of the 

Lower Extremity of the Fibula . . 278 
Dessault's Apparatus for Fracture of the Os 

Calcis . . . . .279 

CHAPTER VIII. 

OF THE IMMOVABLE APPARATUS. 

General Account of . . . . 281 

PART FOURTH. 

CHAPTER I. 

OF THE APPARATUS FOR THE TREATMENT OF DIS- 
LOCATIONS. 

General Considerations ..... 289 
CHAPTER II. 

DISLOCATIONS OF THE HEAD AND TRUNK. 

Dislocations, of Head and Trunk . . . 291 

Lower Jaw . . . .291 

Oblique Processes of Vertebrae . 292 

Ribs . . . . .292 

Clavicle .... 293 

Humeral Extremity of the Clavicle . 294 

CHAPTER III. 

DISLOCATIONS OF THE UPPER EXTREMITY. 

Dislocations, of Upper Extremity . . . 295 

Head of Humerus . . .295 

Fore-arm .... 297 

Head of Radius . . . .298 

Reduction of .... 299 

Diagnosis of Injuries of the Elbow . . 299 

of Bones of Forearm on Wrist . . 300 



CONTENTS. 



21 



Dislocation of all Bones of Wrist . 

of Magnum 

of Metacarpal Bones . 

of Phalanges 
Clove-Hitch 



300 
300 
301 
301 
302 



CHAPTER IV. 




ON DISLOCATIONS OF THE LOWER EXTREMITY. 




Dislocations of Hip-Joint .... 


304 


Fahnestock's Mode of Reducing 


. 305 


Reduction by Pullies 


305 


Dislocation on Pubis .... 


. 307 


into Sciatic Notch 


307 


Foramen Thyroideum . 


. 308 


of Patella .... 


308 


Head of Tibia 


. 309 


Fibula .... 


309 


Bones of Tarsus . 


. 309 


Metatarsal Bones 


310 


Phalanges 


. 310 



PART FIFTH. 



OF THE MINOR SURGICAL OPERATIONS. 
Definition of, &c. 



311 



CHAPTER I. 

OF THE DUTIES OF ASSISTANTS IN OPERATIONS. 



General Considerations 
Rules for Operations 
Administration of Ether 
Smith's Inhaler . 
Duties in Amputations 
Lithotomy 



313 
313 
315 
317 
323 
321 



CHAPTER II. 

OF BLOODLETTING. 

Phlebotomy .... 

Venesection 

Anatomy of Veins of Arm 

Lancets .... 

Spring Lancet .... 

Thumb Lancet 

Operation with Spring Lancet . 



328 
328 
328 
332 
332 
332 
334 



22 CONTENTS. 




Operation with Thumb Lancet 


. 884 


Bleeding in Hand .... 


336 


External Jugular Vein 


. 336 


at the Ankle .... 


338 


Arteriotonry ..... 


. 341 


Local Bloodletting .... 


342 


Leeching ...... 


. 342 


Arrest of Hemorrhage from 


344 


Preservation of Leeches .... 


. 345 


Mechanical Leeches .... 


346 


Cupping ...... 


. 347 


CHAPTER III. 




OP CUTANEOUS IRRITATION. 




General Considerations of . 


. 350 


Blisters ...... 


350 


Cantharidal Collodion .... 


. 351 


Granville's Lotions for . 


853 


Gondret's Ointment .... 


. 353 


Issues ...... 


353 


Issue Peas ...... 


. 353 


Formation of Issue by Potash, Acids, &c. 


353, 354 


Setons ...... 


. 356 


Moxa ...... 


358 



CHAPTER IV. 




OF 


PUNCTURES. 




General Considerations of . 




: 361 


Acupuncturation 


• 


861 


Electro-Puncture . 




. 363 


Vaccination 




363 


Preservation of Vaccine 




. 865 


Perforation of Lobe of Ear 




366 


Puncture of Membrani Tjnnpani . 


. 368 


Paracentesis Abdominis 


. 


368 


Puncture of Hydrocele 




. 370 


Diagnosis of Hydrocele, &c. 


. • . 


372 


Ranula 




. 373 


Salivary Concretions 




374 


Puncture of Abscesses 




. 374 


Diagnosis of Abscesses . 


. 


375 



CHAPTER V. 

OPERATIONS FOR ARRESTING HEMORRHAGE. 

General Consideration of . 



377 



CONTENTS. 



23 



Pressure 

Spanish Windlass . 

Tourniquet of Petit 

Bellingham's Compressor 

Preparation of Sponges 

Ligatures .... 

Preparation of . 
Tenaculum . 
Forceps . 
Surgeon's Knot 
Sailor's Knot 

Torsion .... 
Styptics .... 
Plugging of Nostrils 
Arrest of Hemorrhage from Rectum 
Hemorrhage from Bladder . 



377 
379 
380 
382 
383 
384 
385 
385 
386 
386 
387 



389 
390 
391 



CHAPTER VI. 

OF WOUNDS. 



General Consideration of 
Sutures . 

Interrupted Suture 
Continued Suture 
Twisted, or Hare-lip 
Quilled 
Dry 
Collodion 



392 
392 
392 
394 
395 
396 
397 
397 



CHAPTER VII. 



CATHETEKISM. 



General Consideration of ... 398 

Catheterism of Urethra ..... 398 

Introduction of Catheter .... 399 

Retention of Catheter ..... 401 

A New Mode of Relieving Retention of Urine without Cathe- 
terism ....... 402 

Catheterism of Stomach . : . . 403 

Use of Stomach-pump ..... 405 

Catheterism of Eustachian Tube . . . 406 



CHAPTER VIII. 

OF INJECTIONS. 



General Use of 

Injection of Lachrymal Ducts 



407 
407 



24 



CONTENTS. 



Injection of Lungs . 
into Urethra 
Vagina 
Rectum 



408 
409 
411 
411 



CHAPTER IX. 

OF EXTRACTION OF FOREIGN BODIES, &C. 

General Consideration of . 

Extraction of Teeth ..... 

Cilise .... 

Foreign Bodies from Eyeball 
Matter from Eyelids 
Bodies from Nostrils 
Ear 
Throat 

Dr. Bond's Forceps for 

Trachea 

Matter from Wounds 

Bodies from Rectum 

Urethra 

Corns ..... 

Bunnions .... 

Toe Nail Ulcer .... 

Dr. Meig's Plan of Treating 
Various Operations ..... 

Operation for Tongue-Tie .... 

Lancing the Gums ..... 

Prolapsus Ani ..... 

Reduction of Herniee ..... 

Club Foot ...... 

Pes Equinus ...... 

Varus ...... 

Bandy Legs, or Bent Bones .... 

Insertion of Glass Eye . . 

Excision of Pterygium ..... 

On the Catoptric Examination of the Eye as a Means of 

Diagnosis in Cataract . : . . 

Excision of Uvula ..... 

Tonsils ..... 

Reduction of Paraphymosis .... 

Conclusion . . . . : 



413 
413 
417 
417 
418 
418 
419 
419 
420 
421 
422 
422 
423 
423 
424 
425 
426 
427 
427 
428 
428 
429 
430 
432 
437 
439 
440 
442 

443 
446 

446 
448 
449 



MINOR SURGERY. 



INTRODUCTION. 

The daily duties required of the surgeon call for 
such varied qualifications, not only in his natural 
temperament but also in that which is acquired by 
education, that comparatively few of the great mass 
of medical men are physically fitted for their per- 
formance, or have any inclination to undertake them. 
The physician, therefore, generally avoids those ex- 
citing and dangerous scenes which the coolness and 
nerve of the surgeon alone are capable of directing ; 
and passes through life in the more quiet, though 
not less responsible occupation, of combatting disease 
in its more insidious invasions. 

The necessities of his patients, and the wide extent 
over which he has to travel, not unfrequently, however, 
compel him to combine within himself the functions 
of both branches of medicine ; and, though avoiding 
great operations, to resort to means as purely operative 
as those requiring the extensive use of the knife. On 
this account, Surgery has from an early period been 
divided by most writers into two portions, — one 
termed Minor Surgery, including bleeding, leeching, 
&c, the other designated as Major Surgery, and 
embracing capital operations. Such a division is, 
however, so purely conventional, that there has 
always been a diversity of sentiment in regard to the 
3 



26 INTRODUCTION. 

limits of each department ; some giving to Minor Sur- 
gery the smallest possible amount, whilst others, fail- 
ing to recognise its existence, include all the sur- 
geon's duty under one general head. 

Without intending to settle this long-disputed point, 
I shall, in the following pages, designate as Minor Sur- 
gery, all such duties as every practitioner should be 
able to perform ; and as these acts are generally re- 
garded by operators as of little importance compared 
with their more hazardous operations, the term 
appears, in this light, to be sufficiently appropriate. 

Although the title thus chosen would seem to 
designate that the duties referred to are of a trivial 
character, yet it will soon be seen that they are so 
only in appearance. In general practice, Minor Sur- 
gery is not less important to a practitioner than that 
department endowed with a more pompous title to a 
surgeon. Both require a large amount of information ; 
both involve very materially the comfort of the pa- 
tient; whilst any of the minor operations may pro- 
duce death, the application of a leech having proved 
fatal, and bleeding, bandaging, &c, improperly per- 
formed, having caused the loss of limbs as certainly 
as the more serious operation of amputation. 

To the general practitioner Minor Surgery is the 
more valuable of the two divisions. An important opera- 
tion may be avoided, a minor one must be performed : 
a major operation in many sections of the country is 
a rare event, a minor one of hourly occurrence. It 
should, therefore, receive at his hands that attention 
to which from its daily calls it is justly entitled. 

In the consideration of the subject five divisions 
naturally present themselves, and I shall place them 
in the order in which they can be most advantage- 
ously studied: — 1st. Dressings and Bandages. 2d. 
Handkerchief Bandages and Provisional Dressings. 
3d. Apparatus for Fractures. 4th. Apparatus for 
Dislocations, and 5th. Daily or Minor Operations. 



PART FIRST. 



CHAPTER I. 

ON THE PREPARATION AND APPLICATION 
OF DRESSINGS. 

Although very varied information and skill are 
necessary for the proper treatment of surgical in- 
juries, and especially those requiring the perform- 
ance of operations, yet will the success likely to 
ensue depend in a great degree upon the attention 
subsequently given to the case. The art of dressing 
becomes, therefore, a subject of equal, if not greater 
importance, than that of operating, and should be re- 
garded as a matter of vital consequence, as without 
it all other means would often prove unavailing. 

The object of all dressings being the relief of in- 
jured parts, their application must of course depend 
upon circumstances. As a general rule, dressings 
are intended to preserve injured parts in proper co- 
aptation ; unite them, or prevent their too hasty 
union ; shelter them from the action of the atmo- 
sphere or of external injuries; absorb discharges; 
prevent dessication of surface ; and last, though not 
least, ensure cleanliness. Dressings may, therefore, 
be denned as those portions of different substances 
applied with such intentions directly to operated or 
injured surfaces. 

The different articles employed, and the means by 



28 PREPARATION AND 

which they are to be applied, are known under the 
general head of Apparatus of Dressing. This 
consists of two parts, one containing the Instruments 
for Dressing, the other the Pieces of Dressing to be 
applied. 

The Instruments for Dressing must vary accord- 
ing to the nature of the case, but usually they may 
be limited to such as are generally found in the as- 
semblage furnished by the cutlers, and known under 
the name of the Pocket Case. This, if required for 
general use, should contain Dressing or King For- 
ceps; Simple Forceps; Scissors, both straight and 
curved ; Probes ; Directors ; Spatulae ; Bistouries ; 
Abscess-Lancets ; one male and female Catheter ; a 
Porte Caustic ; a Tenaculum ; Straight and Curved 
Needles; Ligatures; and often such others as the 
taste of the cutler or his interests may lead him to 
select. Under this head, also, the surgeon should, 
in serious cases, include Razors, Basins, Sponges, 
Towels, Buckets, &c. ; in fact, all that is requisite for 
the preparing of a part for the application of a dress- 
ing, or the removal of the previous one. 

As the proper use of the instruments just referred 
to is not always known by those purchasing them, 
a brief description of the objects and method of 
handling each may not be out of place. 

The Dressing Forceps are employed for remov- 
ing the different pieces of dressing, not only in order 
to protect the fingers of the surgeon from discharges 
that are often very irritating, but also on account of 
their enabling him to seize them with less risk of in- 
jury to surrounding parts, especially by pressure. 
In cases of fistulse or sinuses they are also often 
necessary, in order to cleanse the bottom of the sinus, 
or remove deep-seated portions of dressing, or other 
foreign matter. In using them, the thumb and 
second finger are to be passed through the rings of 
the handle, and the fore-finger extended towards the 



APPLICATION OF DRESSINGS. 29 

joint of the blades, in order to render them more 
firm. 

The Simple or Dissecting Forceps may be fre- 
quently substituted for the Dressing Forceps, espe- 
cially where minute portions of dressing, such as liga- 
tures, &c, are to be removed. They are, however, 
more frequently used for seizing such portions of 
integument as may require to be cut off by the knife 
or scissors. As similar forceps are employed by each 
student in dissection, no information need be here 
given as to the manner of using them. 

The Straight Scissors are employed in dressing, 
for the ordinary purposes of scissors ; but those which 
are Curved, either on the side or front, are mainly 
required to facilitate the removal of such dressings 
as adhere closely to the body ; as adhesive strips, 
bandages, &c, especially where it is desirable to re- 
move them without deranging the position of the part. 
Scissors are also occasionally used for excision of 
portions of integuments, as in hair-lip ; but they do 
not answer as well as the scalpel for such operations, 
because they are apt to bruise the edges of the part 
divided, and thus interfere with its subsequent adhe- 
sion. If scissors have a rough edge and cut harshly, 
light pressure of the thick skin of the thumb along 
the blades will remove it. 

Probes are intended as substitutes for the fingers 
where the space to be examined is too narrow to 
admit a larger body. But where it is possible to in- 
troduce the finger it should always be preferred, on 
account of the greater accuracy of the touch. The 
probe should always be made of silver, or some equally 
flexible metal, in order that it may be readily bent, 
to suit the position of the part to be examined. 

The Director is a broad probe with a groove in 

it, which is generally used to direct the point of a 

scalpel or bistoury, in the division of deep-seated 

parts, especially where important organs are in the 

3* 



30 PREPARATION AND 

neighbourhood of the incision. Sometimes it is 
formed with a flat end for a handle, and sometimes 
it has a ring or other slight expansion to keep it 
from turning in the fingers of the operator. When 
the director is required to facilitate incisions, it 
should be held with the thumb on the top of the 
handle, and the fingers of the same hand beneath its 
shaft, in order to prevent its slipping out of place. 
The knife being held in the opposite hand, is then 
made to pass along the groove as far as may be 
desired. 

The Spatula requires but little description. It 
may be used either in spreading cerates, in the pre- 
paration of dressings, &c, or for removing such por- 
tions of similar substances as remain adherent to the 
skin. 

Bistouries and Scalpels are of various shapes, 
and should be selected mainly with reference to the 
probable wants of the practitioner. As their use 
varies much in the different operations to which they 
are applicable, the reader is necessarily referred to 
the works on Operative Surgery for any further in- 
formation than will be found in Part Fifth of this 
volume. 

Abscess Lancets resemble the ordinary thumb- 
lancets, except that they are larger. The manner 
of using them will be referred to under the head of 
Operations. 

The Porte-Caustic or Caustic Holder is em- 
ployed as its name designates. It is usually armed 
with the Nitrate of Silver, or Lunar Caustic, and not 
with the caustic potash. As a general rule, the holder 
should be made of silver, with platina ends, as this 
metal is not acted upon by the caustic, whereas bone 
or similar substances, of which it is sometimes formed, 
are soon destroyed. When it is desirable in arming 
the holder to give the caustic a fine point, so as to 
enable us to touch only small spots, as in the treat- 



APPLICATION OF DRESSINGS. 



31 



ment of ulcerated cornea, chancre, &c, it will be 
best accomplished by rubbing the caustic with a 
piece of wet rag, so as to wear it away, rather than 
by scraping, as the brittleness of the nitrate of silver 
renders it difficult to bring it to a point merely by the 
use of the knife. 

The Straight and Curved Needles, Tenacula, 
Ligatures, &c, will be treated of under another 
head, whilst the other instruments of dressing, as 
Razors, &c, are so simple as only to require the 
mere mention of them in order to guard against 
their omission in the Apparatus of Dressing. 

The Pieces op Dressing are Lint ; Charpie ; Cot- 
ton; Tow; Spread Cerate, or other ointments ; Com- 
presses ; Malteese Cross ; Shields for Amputations ; 
Adhesive Strips ; Setons ; Poultices ; Plasters ; and 
means of Irrigation. 

Lint is a soft, delicate tissue or mass, prepared in 

Fig.l. 




two ways, in one of which the transverse threads of 



32 PREPARATION AND 

soft old linen are drawn out by a machine, leaving the 
longitudinal ones covered by a sort of tomentum or 
cotton-like mass ; whilst, in the other, the cotton-like 
surface is produced by scraping with a sharp knife 
a similar piece of cloth previously fastened to some 
firm substance. The first is known as the Patent 
Lint, and may be obtained of any druggist, being 
now generally manufactured. The second is the 
Domestic Lint, and may be made at a moment's 
notice when the first is not convenient. They are 
both employed as primary dressings, either spread 
with ointments, or alone. 

Charpie is a substance much employed by the 
French surgeons, and now gaining a more general 
application in the United States. It is made by col- 
lecting the threads torn from pieces of linen, four or 
five inches square, such as is used for patent lint. 
The process, however, goes a step farther than that 
for making lint, and tears the threads entirely apart 
instead of preserving the cloth. The linen from which 
it is made should always be new, and not worn out 
table-cloths, &c, as sometimes employed; Gerdy 
having proved, that when Charpie is made from new 
linen it absorbs better than when from old ; Charpie 
is usually divided into two kinds, according to the 
length and fineness of the thread composing it ; that 
which is long and coarse being employed to keep 
open sinuses, fistulse, and to act as an outer dress- 
ing ; while the softer, finer kind is placed in imme- 
diate contact with the part, especially where the 
surface requires stimulation. 

Various names are given to Charpie, according to 
the way in which its fibres are arranged previously 
to its application. Thus, we have the Pledget, Roll, 
Tent, Mesh, Bullet, Tampon, Pellet, &c, each of 
which have their peculiar advantage. 

The Pledget is a mass of charpie formed by col- 
lecting the threads and laying them parallel to each 



APPLICATION OF DRESSINGS. 



33 



Fig. 2. 




Fig. 3. 



other, with the ends folded underneath. This being 
flattened between the palms of the 
hands, may be made of an oval, 
spheroidal, or square shape, accord- 
ing to the nature of the part on 
which it is to be applied. As thus 
formed, the pledget is usually 
spread with cerate, and neatly 
adapted to the parts it is to cover ; 
care being taken not to make it so 
thick as to overload and heat the 
surface of the wound, nor yet so 
thin as to permit the Pledget becoming quickly 
saturated with pus. Where charpie cannot be ob- 
tained, the patent lint, cotton, or tow similarly 
arranged, may be substituted. 

The Roll is a smaller mass of charpie, 
formed by rolling its fibres longitudinally 
between the hands, so as to make an ob- 
long mass, which is then tied firmly in the 
middle, in order that when the ends are 
brought in contact laterally, it may form a 
sort of cone. It serves for absorbing pus in 
deep wounds where there is a tendency in 
the edges to close before the bottom has 
filled up. It is also useful in arresting he- 
morrhages from deep-seated vessels ; pres- 
sure being made by forcing the central part upon the 
vessel so that the loose tissue made by the ends may 
assist in the formation of the clot. A director, probe, 
or dressing forceps is necessary, in order to carry it 
in to deep wounds or upon a vessel. 

The Tent is a conical or 
cylindrical mass of charpie, 
formed like the roll, except that 
instead of applying a string 
to the middle, it is there simply 
doubled on itself, the loose ends 
being twisted by the fingers, so as to give it a spiral 




Fig. 4. 




34 PREPARATION AND 

form and make the apex of a cone, of which the base 
is the part where the fibres are doubled on them- 
selves (Fig. 4). This is also employed to dilate 
fistulous canals, where the orifices are too small to 
allow of the free escape of pus, and where only moder- 
ate dilatation is required. But where parts are rigid, 
the Sponge Tent, or that made by slicing gentian, 
carrot, or some other porous root into the shape 
of a cone, or plug, will be found to answer better, as 
it expands more powerfully. 

The Sponge Tent is the one most generally em- 
ployed, and certainly answers best in the majority of 
cases. It is prepared by soaking common sponge in 
melted bees-wax ; allowing it to cool and harden, and 
then slicing it into small pieces, of such a size as will 
nearly fill the orifice to be dilated. The heat of the 
part melts the wax ; the sponge fills with the fluids 
of the tissues, and gradually dilates them 
to the size required; after which a new 
and larger morsel must be introduced. 

The Mesh is formed of the threads of 
charpie, placed parallel with each other 
and then bent on themselves. It is of 
great use in the treatment of deep 
fistuhe, especially fistula in ano. When 
thus used, it should be anointed with 
cerate and introduced into the cavity 
on the point of a probe until it nearly 
touches the bottom. It acts by pre- 
venting the edges from healing, thus 
causing the cavity to fill from below, upwards. 

Bullets are little balls made by rolling charpie 
between the hands until it acquires this form. They 
are extremely porous, absorbent, and useful in filling 
up purulent cavities, where they prevent matter from 
burrowing. 

When a number of Bullets are placed together at 
the bottom of any cavity, either with a view of dis- 




APPLICATION OF DRESSINGS. 



35 



Fig. 6. 




Fig.l. 



tending it or of arresting hemorrhage, they take the 
name of Tampon. They are 
often thus used in gonor- 
rheal inflammations of the 
vagina ; in fluor albus ; and 
to arrest uterine hemor- 
rhage. For the latter pur- 
pose, especially if the hemor- 
rhage follows an operation, 
or a laceration of the neck of 

the womb, they may be made of the Boletus Igniarius, 
or puff-ball. 

The Pellet is a large bullet surrounded by a piece 
of soft rag, the edges of which are 
brought together and tied firmly (Fig. 
7). It is occasionally employed in the 
treatment of hernia, especially the um- 
bilical hernia of children, where, when 
bound down by adhesive strips, or a 
bandage, it answers very well the pur- 
poses of a truss. It is also useful in the compression 
of large vessels, as in wounds of the axillary artery ; 
in the reduction of dislocations into the axilla, and 
in hemorrhage from parts in the neighbourhood of 
the rectum, being there confined under a T bandage. 

In the hemorrhage which sometimes follows the 
extraction of a tooth, a very useful pellet may be 
formed, by cutting a bottle cork into a cone and forc- 
ing it into the socket with a little lint, simply by 
closing the jaws. 

For the convenience of those who may desire to 
obtain charpie in this country, I would state that it 
can now be obtained from most of the druggists in 
Philadelphia, of an excellent quality, at very little 
more than the cost of patent lint. 

Cotton and Tow are substances which are too 
well known to require a description. Both are of 
comparatively limited utility as surgical dressings, 




36 PREPARATION AND 

their places being usually supplied by charpie. Be- 
fore, however, the application of either of them to 
surgical purposes, they should be well picked or 
carded, to free them from foreign matter. The chief 
use of cotton is as a dressing to superficial burns, 
where it is useful by protecting them from the air, 
absorbing the discharges, and forming a sort of scab 
under which the skin readily heal. When intended 
to be thus used, it is, however, especially necessary 
to see that it is free even from specks, as the fly is 
exceedingly apt to lay its egg in it, and this being 
vivified by the heat of the body, generates maggots, 
to the great annoyance of the patient and the aston- 
ishment of all around him, who, under the belief that 
he is eaten of worms, usually regard it as a fatal sign. 

Tow is employed chiefly as an outer dressing to 
stumps which are discharging freely, in order to pro- 
tect the bed. Care is requisite in forming the Pled- 
get of Tow for this purpose, that it be not too thick 
and heating, as union is often thus prevented. But the 
advantages to be derived from the use of Tow under 
any circumstances may, I think, be doubted, stumps 
having in very many instances done better with irriga- 
tion than when dressed in the old style. Since the in- 
troduction of oiled silk, caoutchouc cloth, &c, a bed 
can readily be protected from dampness, whilst the 
evidence in favour of the water dressing in the treat- 
ment of amputations is daily accumulating. With the 
use of collodion instead of adhesive plaster, and the 
water dressing instead of grease and tow, the treat- 
ment of stumps is less inflammatory than it for- 
merly was, and results in better surfaces. 

Compresses are pieces of linen of various sizes, 
used to make pressure, confine dressings, prevent 
external injuries, and equalize the surface of limbs, 
in order better to adapt them to the application of 
the bandage, or the compression of the soft parts. 
Compresses should be made of some soft substance, 



APPLICATION OF DRESSINGS. 



37 




as flannel, muslin, calico, &c, and with one or two 
exceptions applied over other dressings. When in- 
tended as a direct application to wounds they should 
always be made of soft linen or lint. 

Compresses have received various names, accord- 
ing to the way in which the cloth is 
folded, or the indications to be fulfilled ; -%• 8 - 

thus, we have the Square, Oblong, Tri- 
angular, and Cribriform Compress, the 
Malteese Cross, the Half Malteese 
Cross, the Single and Double Split 
Compress, as well as the Perfor- 
ated, Graduated, and Pyramidal Com- 
presses. 

The Square Compress is that in 
which the substance used has the same 
dimensions in its two principal diame- 
ters. When the square is folded so 
that it is twice as long as it is broad when doubled 
in its length, it constitutes the 
Oblong Compress, or Band, Fi 9- 9 - 

and is useful in surrounding a b 

the trunk or limbs. If the 
square piece is folded so as to 
unite two of it angles, it forms 
the Triangular Compress 
(Fig. 9). This compress will 
be found exceedingly useful in 
confining dressings to stumps, where it is desirable to 
remove the dressing frequently without deranging 
the limb, as in the use of poultices, &c. To apply 
one for this purpose, cut it of such a size as will sur- 
round the limb, place the stump in the centre of the 
side a b (Fig. 9) ; then turn up the apex e, and after- 
wards the points a and b, confining them by pins. 
Then when it becomes necessary to change the poul- 
tice, loosen the ends, and turning them back the 
surface will be exposed to view. 




38 



PREPARATION AND 



Fig. 10. 




The Cribriform Compress is a square piece of 
linen in which a number of holes are cut. It is formed 
by folding linen four or six 
times on itself, so as to make 
several oblong squares, one 
within the other ; then nick the 
sides in several points with the 
scissors so as to remove small 
pieces, and on opening it out 
we shall have the form desired 
(Fig. 10). When spread with 
cerate and applied directly to 
a suppurating surface, the pus, 
passing out through the holes, will allow the com- 
press to remain directly in contact with the surface, 
and thus prevent the wound from being constantly 
bathed in matter, which sometimes is unhealthy. 
The cerate with which this compress is spread is 
useful not only by favouring the removal of other 
portions of dressings, but also when thus kept 
directly in contact with the granulations, by pro- 
moting cicatrization. 

The Malteese Cross, so named from its shape, is 
made from a square piece of linen, by 
folding it first into an oblong square ; 
doubling this so as to form a smaller 
square ; joining the two angles to form 
a triangle, as in (Fig. 11), and folding 
this equilaterally, to form a smaller tri- 
angle. Then mark a line on its hypo- 
theneuse half an inch from its apex, 
and slit the sides down to this line, as 
in that which is dotted in the figure. 
On opening out the linen we have a 
very regular cross, with a space in the centre (Fig. 
12), intended to cover the front of the stump, whilst 
the angles go around it, and can be neatly adjusted 
to the convex surface of a stump without creating 



Fig.W. 




APPLICATION OF DRESSINGS. 



39 



Fig. 12. 



folds. This cross is mainly used as a primary or 
secondary dressing in am- 
putations. 

The Half Maltebse 
Cross (Fig. 13) is formed 
by slitting the two angles 
of the loose side of an ob- 
long square to within an 
inch or two of their centre, 
as seen in the figure. In 
some cases it serves a better 
purpose than the full cross ; 
as in dressing stumps at the 
shoulder, or hip-joint. If 




Fig. 13. 




Fig.U 



the linen is doubled and 

cut in this form it will, 

when opened out, form the 

cross (Fig. 12) as readily 

as the one in the plan 

there stated. In order to 

appreciate the value of these directions 

the student should repeat them on a 

piece of paper. A little practice with 

the scissors according to the lines just 

described, will soon render very easy 

the manufacture of these portions of 

dressings. 

The Retractor of Two Tails (Fig. 
14) is made of an oblong piece of mus- 
lin split as represented in the figure, 
and intended to be used as a shield to 
the soft parts, in amputations where 
there is but one bone to be divided by 
the saw, as in the arm or thigh. In 
applying it draw the tails downwards 
on each side of the bone, and the upper 
part or body of the retractor, upwards 
over the stump, so as to force back the 
muscles and protect them from the action of the saw. 



O 



40 



PREPARATION AND 



Fig. 15. 



The diamond-shaped opening at the end of the split 
is intended to adapt it more accu- 
rately to the bone itself. 

The Retractor of Three Tails 
(Fig. 15) is made like the preced- 
ing, only it is split into three tails 
instead of two. It is employed in 
the same manner, in amputations 
where there are two bones to be 
divided, as in the forearm and leg ; 
the third or middle tail being pushed 
through the interosseous space, so as 
to protect more thoroughly the soft 
parts around both the bones. 

The Perforated Compress (Fig. 
16) is the name given to a piece of 
muslin folded several times on itself, 
so as to make a thick mass, in the 
centre of which an opening is cut. 
It is used in order to relieve points 
from pressure, especially where they 
have a tendency to slough, as on the internal con- 
dyle in fractures of the elbow, or on the 
trochanter of the femur, or on the heel, 
in fractures of the lower extremity. The 
sore point being placed in the centre of 
the opening is saved from the weight, 
whilst the pressure is borne by the cir- 
cumference. Frequently it is made out 
of a small pad or pillow, cut and formed 
like a broad ring. A very excellent 
article of this kind is now made of India rubber 
cloth, so that it can be inflated. Such pads may be 
obtained at most manufactories, and should be made 
indispensable articles in hospital practice. But in 
any case strict attention must be paid to the parts 
of the limb pressed on by the circumference of the 
opening. 




Fig. 16. 




APPLICATION OF DRESSINGS. 



41 



Graduated Compresses are named from their con- 
struction, and are of several kinds ; the substance of 
each being folded differently, according to the object 
in view. 

The Common Graduated Compress is made by 
folding a piece of muslin seve- 
ral times on itself, so that 
each fold may not entirely 
cover the one that has pre- 
ceded it. It may be gradu- 
ated at one end, as in the 
the cut, or from end to end, as would be the case if 
Fig. 17 had another folded end at its left extremity. 

The Pyramidal Compress is 
that is most accurately 



Fig. 17. 









Fig. 18. 




Fig. 19. 



one tnat is 

formed by placing square pieces 
of muslin, gradually decreasing 
in size on top of each other, and 
stitching them together so as to 
form a pyramid (Fig. 18). It 
may also be made by folding a 
piece of 2J inch bandage on 
itself, so as to form a pyramid 
graduated from end to end, and then placing a piece 
of cotton, or other sub- 
stance, in the centre of the 
last turns (Fig. 19). Thus 
formed, it is very useful in 
making pressure upon cer- 
tain points, as in cases of 
hemorrhage from the deep-seated vessels of the leg 
or forearm. 

Adhesive Strips are pieces of linen spread with 
some adhesive plaster (usually Diachylon), and in- 
tended to promote the union of divided parts by 
approximating their edges or protecting the surface 
from the action of the air. As this plaster is kept 
very generally by the druggists, the formula for its 
4* 




42 



PREPARATION AND 



composition would here be out of place. When the 
strips are wanted they may be prepared from the 
sheet on which it is usually spread by sliding the 
scissors according to the line of the thread of the 
cloth, so as to slit it into pieces about three-quarters 
of an inch in width (Fig. 20), and of a length suffi- 
cient to enable it to extend at least three inches be- 



Fig. 20. 




yond each side of the wound. Before applying them 
it is generally necessary to soften the plaster by heat, 
and the most convenient method of so doing is to fill 
a bottle with boiling water and wrap the strip around 
it ; the outside of the strip being next the surface of 
the bottle. In its application to wounds, the strip 
should be first placed on that portion of the surface 



APPLICATION OF DRESSINGS. 



43 



which is most depending, in order to draw it up to 
the other, and not applied from above downwards. 
The intervals between the strips should be such as 
will allow of the free escape of matter. In order to 
remove the strips from a wound without injury, wash 
the part with warm water, or apply a warm poultice to 
it a few hours before the dressing is to be changed. 
After this let the dresser lay hold of one of the ex- 
tremities of each piece in succession, and gently 
raising one end reflect it upon the wound to within 
an inch of the edge. Then detach the other to about 
the same distance, and holding the two ends together, 
lift the strip perpendicularly from the part, taking 
care at the same time to apply the thumb and index 
finger of the left hand on the sides of the wound, to 
prevent too great stress upon the new cicatrix. The 
manner of removal is shown in Fig. 21. 



Fig. 21. 




Adhesive strips sometimes irritate and inflame the 
skin, owing either to their tearing out the small hairs 
or down which cover it, or to the plaster being badly 
made, and their application is, therefore, frequently 
followed by erysipelas. In this case their place may 
be very well supplied by the slit and tail, or uniting 



44 PREPARATION AND 

bandage, or by the Collodion, as hereafter shown. 
Adhesive strips are also much used as a dressing to 
ulcers; for compression in cases of epididymitis or 
hernia humoralis, &c, &c. : 

As the treatment of ulcers by means of these adhe- 
sive strips has gained much celebrity, a detailed ac- 
count of Baynton's plan is here given : 

"The parts," says Mr. Baynton, "should be first 
cleared, by means of a razor, of the hair sometimes 
found on them in considerable quantities, so that 
none of the discharges by being retained may become 
acrid and inflame the skin, whilst the dressings may 
be removed with ease at each time of their renewal. 
This, in some cases, where the discharges are very 
profuse and the ulcers irritable, may perhaps be 
necessary twice in twenty-four hour. After this 
preparation, several strips of adhesive plaster, about 
two inches in breadth, and of a length that will, 
after being passed round the limb, leave an end of 
about four or five inches, are to be applied to the 
sound part of the limb, the middle of the strap being 
opposite to the inferior portion of the ulcer, so that 
the lower edge of the plaster may be placed about 
an inch below the lower edge of the sore, and the 
ends drawn over the ulcer with as much gradual ex- 
tension as the patient can well bear. Other slips 
are to be secured in the same way, each above and 
in contact with the other until the whole surface of 
the sore and the limb are completely covered, at least 
one inch below, and two or three above the diseased 
part. 

" The whole of the leg should then be equally de- 
fended with pieces of soft calico three or four times 
doubled, and a bandage of the same about three 
inches in breadth and four or five yards in length, 
or, rather, as much as will be sufficient to support the 
limb from the toes to the knee, should be applied as 
smoothly as possible, and with as much firmness as 
can be borne by the patient. 






APPLICATION OF DRESSINGS. 45 

"If the parts be much inflamed, or the discharges 
very profuse, they should be well moistened and kept 
cool with cold spring water poured on them as often 
as the heat may indicate to be necessary, or perhaps 
at least once in every hour. The patient may like- 
wise take what exercise he pleases, and it will be 
always found that an alleviation of his pain, and the 
promotion of his cure, will follow as its consequence, 
though under other modes of treating the disease it 
aggravates the pain and prevents the cure. The 
first application will sometimes occasion pain, which, 
however, soon subsides, and is felt less sensibly at 
every succeeding dressing. The force with which 
the ends are drawn over the limb must then be gra- 
dually increased until the parts are restored to their 
natural state, especially if the limb be in that en- 
larged and incompressible state which has been de- 
nominated the scorbutic. 

"If the patient be of a spare habit, it may be 
necessary to guard against excoriation by defending 
the tendo-Achilles with a small shred of soft leather, 
previously to the application of the adhesive slips." 

This plan, although published by Mr. Baynton in 
1797, has had many opponents among the Eng- 
lish surgeons, some of whom yet deny entirely its 
utility, or insist that it can be replaced by better and 
and less troublesome means, such as bandages, &c. 
But the experiments of Velpeau, Boux, and many 
others of the French surgeons, have established very 
conclusively the fact that it requires only about half 
the time to cure an ulcer under Baynton's plan that 
it did under the old system of ointments, &c. Vel- 
peau, in 1840, also enlarged considerably the use of 
adhesive strips, on the principal of Baynton, as a 
means of making pressure in the treatment of other 
surgical diseases besides ulcers, such as chronic en- 
largements of the joints ; in wounds in which it is 
difficult or improper to heal by the contact of the 



46 PREPARATION AND 

edges, on account of deformed cicatrises; in the 
treatment of burns ; in ganglia, or other tumours 
about joints; in scrofulous ulcers of the neck, 
especially when presenting thickened edges or those 
which are undermined ; and in different ulcers of the 
mammary region where otherwise cicatrisation Avould 
be extremely slow. "In Burns," says he, "the ad- 
hesive strips act marvellously well. In those of the 
first degree, one application of the strips, sustained 
slightly by a compressing bandage, and which may 
all be removed from the fourth to the eighth day, is 
sufficient to effect a cure. If it is a burn of the 
second degree, that is, one with blisters, and not 
attended with much phlegmonious inflammation, I 
remove the cuticle, cleanse the exuded matter, apply 
the strips and obtain a cure at the end of the second 
dressing, sometimes at the first, and nearly always 
at the third ; so that if it is not cured by the fourth, 
it will be better to change the treatment. If there 
is much engorgement, with a tendency to erysipelas, 
I commence by an emollient poultice, or a few leeches, 
and then apply the strips. If the burn is of the third 
degree, that is to say, with change of structure, or 
conversion of the true skin to an eschar, the same 
treatment is pursued, and the cure is not less certain ; 
only it exacts here ten or twenty days. When the 
burn is yet deeper and comprises the whole thickness 
of the derm, as the strips cannot do away with the 
necessary loss of substance in the separation of the 

Fig. 22. 




eschar, it is useless to apply them before it has 
separated; that is, after the formation of the ulcer." 
It must, however, be recollected that Velpeau 



APPLICATION OF DRESSINGS. 47 

changes the strips every three or four days, and not 
every twenty-four or forty-eight hours, as proposed 
by Baynton. 

Mr. Critchett, in the English Lancet for 1848, has 
again called the attention of the profession to the 
advantages of compression in the treatment of ulcers 
of the lower extremity, by a plan, which though not 
novel, has yet much to recommend it. Starting with 
the proposition that ulcers in the lower extremity are 
difficult to heal in consequence of the pressure of 
the superincumbent column of blood weakening the 
vessels and impeding the circulation through the 
part, he suggests the uniform support of the entire 
limb by the application of adhesive strips. Having 
tried in a few cases of indolent ulcers his plan of 
treatment, I have been sufficiently satisfied with the 
results to join in his recommendation. 

In its application the following directions will be 
found useful : — " Seat the patient opposite to you 
aud support his foot on a low stool, so that the foot 
may rest on the point of the heal and near the edge 
of the stool. Then with strips of adhesive plaster 
about two inches wide and twelve or eighteen inches 
long, according to the size of the limb, apply the 
centre of the first strip low down to the back of the 
heel, and then with the flat part of both hands press 
the plaster along both sides of the foot," continuing 
the strips as high up the limb as may be necessary 
to give efficient support to the vessels. 

In my experience, five inches above the ulcer has 
been sufficient; but Mr. Crichett has not stated 
whether or not he intends the application literally 
to cover the whole limb ; that is, to the groin. 

The advantages of this plan will be found in the 
ability of the patient to walk about whilst the ulcer 
is healing instead of being confined to bed. For a 



48 



PREPARATION AND 



Fig. 23. 



full account of the subject I must refer the reader to 
Rankin's Abstract, No. 9, June, 1849. 

Nothing answers so well for a compressive bandage 
of the testicle in cases of Epididy- 
mitis, or chronic enlargement of 
the testicle, especially after free 
leeching, as a firm compression of 
the part by strips of adhesive 
plaster, as practised by Ricord 
and Fricke. In order to apply 
them in this case, the swelled tes- 
ticle should be forced to the bot- 
tom of the scrotum by surround- 
ing the cord with the thumb and 
fingers of one hand so as to form 
a ring, while with the other, or 
with the hand of an assistant, the 
strips are so applied as to surround 
the part entirely, as seen in Fig. 23. 
These strips should be of the width 
of the thumb, and applied over one another from 
below upwards, till the testis and a part of the cord 
are compressed between them. Previous to their 
application the parts should be cleansed and well 
shaved; the strips warmed enough to make them 
adhere, and then be renewed as often as the abate- 
ment of the swelling in the testicle may render them 
slack. 

It may perhaps be useful to the young surgeon to 
say, that the use of adhesive strips to suppurating 
surfaces often produces a marked blackness of the 
skin. This is nothing but a chemical change pro- 
duced in the plaster by the action of the discharges, 
and not the forerunner of gangrene, as many have 
at first supposed. 

Considerable objection has been raised within the 
last few years to the use of adhesive strips as a 
means for uniting wounds, on the ground that they 




APPLICATION OF DRESSINGS. 49 

proved irritating, and gave rise to erythema and 
erysipelas. As a substitute for it, the Isinglass 
plaster has been highly recommended in England as 
possessing equal adhesive powers, and having the 
advantage, on account of its transparency, of en- 
abling the surgeon to see the state of the wound 
through the plaster. 

"It is composed," according to Mr. Liston, "of a 
solution of isinglass in spirit, and may be spread for 
use, as occasion requires, on slips of oiled silk; on 
silk glazed on one side only, and on the unglazed 
side. It is cut into strips of the desired breadth, 
and the adhesive matter dissolved immediately before 
it is employed, by the application of a hot, moist 
sponge." This plaster has been used to some extent 
in the United States, but with what results I am un- 
able to say. My own experience is against it, the 
warmth of the part and the discharges having invari- 
ably softened the material to the same extent that 
the sponge did previous to its application ; in conse- 
quence of which it invariably lost its hold. 

Collodion, or the Liquid Adhesive Plaster, is 
an article recently brought to the notice of the pro- 
fession by Dr. Maynard, of Boston. 

It is formed, according to a formula published by 
Mr. Edward Parrish in the Philadelphia Journal of 
Pharmacy for October, 1849, by treating cotton with 
nitric and sulphuric acids, and then dissolving it in 
ether. As the formula will probably be introduced 
into the U. S. Pharmacopeia, it would be out of place, 
at present, to do more than mention that I can testify 
to its excellence from having used it extensively. 
The non-contractile Collodion suggested by Mr. Rand 
in the previous number of the same journal, I have 
not liked so well, the contractility of the Collodion 
being a strong point of recommendation in the treat- 
ment of wounds. In applying the liquid to slight cuts, 
it is generally sufficient simply to paint the surface a 
5 



50 PREPARATION AND 

few times with a camel's hair pencil. But in more 
extensive wounds, strips of kid or muslin may be wet 
with the solution, and then pressed on the part until 
dry, this usually happening in a few minutes after the 
application, from the rapid evaporation of the ether. 

The advantages of Collodion over adhesive strips 
will be found in its more permanent adhesion, neither 
heat nor moisture nor anything but ether being able 
to soften it. It also enables the surgeon to approxi- 
mate parts without irritating the edges of a wound 
by contact with the plaster ; whilst its tenacity is so 
great, that an adhesion of the end of a strip for one 
inch will be capable of sustaining a weight of several 
pounds. 

Collodion has, also, proved an excellent dressing in 
sore nipples, excoriated surfaces, burns, ulcers, small 
ncevi, &c, &c, of which numerous cases have been 
recently published. 

In the after-treatment of hare-lip, wounds of the 
scalp, dissecting punctures, &c, I have found it act ad- 
mirably; and when applied to oil silk, in a manner 
similar to that directed for court plaster, the silk being 
moistened with a little ether immediately before its 
application to the skin, it has proved a firm and 
neat dressing. From the numerous purposes to which 
Collodion has been recently applied, the article is evi- 
dently, as yet, only in its infancy. (See Blisters.) 

Court Plaster, sometimes called gummed silk, is 
occasionally used in slight wounds and excoriations, 
although mainly in domestic practice. The English 
court plaster, which is generally deemed the best, is 
made by placing one part of choice isinglass, cut into 
little pieces, in an earthenware vessel upon a sand 
bath, and digesting it in four parts of water. When 
this is dissolved, it is strained through a fine linen 
cloth ; eight parts of alcohol are added, and it is 
evaporated to one-half, again strained, and the tepid 
liquid then spread upon black silk with a camel's hair 
pencil. Four or five layers are thus put on, care being 



APPLICATION OF DRESSINGS. 



51 



taken to see that the former is perfectly dry. Be- 
tween the last two coats of the Icthyocolla, a little 
Tinct. of Benzoin or Bals. Peru is added to give it 
an agreeable flavour. Thus prepared, the plaster is 
allowed to dry for twenty-four hours. When used, 
a piece is to be moistened by placing the gummed 
side on the tongue and immediately applied." 1 

Poultices or Cataplasms are different kinds of 
pulp or pastes, intended to cover injured surfaces, 
the character of the substances being varied according 
to the object to be gained from their application. 

The Emollient Poultice may be made of any 
mild, unirritating substance, as bread and milk; 
bread and water ; bran and water ; corn-meal and 
water ; and ground flaxseed, or flaxseed meal. The 
latter forms decidedly the best poultice, not only as 
regards its properties, but also its economy. It is 
prepared by pouring hot water on the meal, and 
stirring till the paste acquires such a consistence as 
will prevent its running from softness, or drying and 
breaking off from being too 
stiff. In order to spread the 
poultice, a portion of the paste 
should be dropped on a suitable 
piece of muslin, and levelled of 
an even thickness, say about 
one-fourth or half an inch ; the 
free ends of the muslin being 
then folded over so as to form a 
sort of frame or border, and 
prevent the adhesion of the 
edges, or their hardening (Fig. 24). If the meal is 
not fresh it will be necessary to rub. a little sweet 
oil or lard over the surface of the poultice, or to 
cover it with a piece of fine gauze previously soft- 



Fig. 24. 




BOURGEBY. 

An analogous preparation will be found in the U. S. Dispensatory. 



52 



PREPARATION AND 



Fig. 25. 




ened in warm water, which will prevent its adhesion 
to surrounding parts (Fig. 25). 

Every poultice should be re- 
newed at least twice in twenty- 
four hours, or more frequently 
if it becomes hard and dry. 
Care must also be taken that 
the meal has not fermented, or 
the oil, if used, become rancid, 
as the application will then irri- 
tate instead of soothing the part. 
The bread and milk, or bread 
and water poultice, is made by breaking the crumb 
of bread into either of these liquids till they have the 
proper consistence, when they may be spread and 
used like that first mentioned. This and every other 
poultice will be more useful if covered on the outside 
by a piece of oil silk, as this will prevent its becoming 
hard and stiff. 

The Astringent Poultice is formed of the above 
by adding any astringent article. Frequently it con- 
sists of bread and lead-water, or of a curd made by 
throwing alum into boiling milk and straining off the 
whey, or rubbing alum up with the white of egg. 
The oak bark, pomegranate, persimmon, nutgall, 
bistort, tormentilla, &c, are also sometimes em- 
ployed, beaten into a pulp, or mixed with other and 
more adhesive or farinaceous substances. They may 
be used in any proportions. 

The Stimulating Poultice is formed of various 
substances, as boiled carrot grated down to a pulp ; 
raw potato grated and applied cold; grated onions; 
grated horse-raddish; cloves of garlic; black pepper; 
or corn-meal and some fermenting liquor, as yeast 
or porter. An excellent stimulating poultice, espe- 
cially adapted to scrofulous or indolent ulcers, may 
be made by thickening strong brine with corn-meal ; 
but to prevent its drying too rapidly this poultice must 



APPLICATION OF DRESSINGS. 53 

be spread on, or covered with the oiled silk as before 
stated. 

The Fermenting Poultice, or that made of corn- 
meal and porter, it must be especially remembered 
should, also, always be spread on or covered with oiled 
silk ; and should, likewise, be covered by the gauze 
to prevent its adhesion. In cases of sloughing, mor- 
tification, hospital gangrene, &c, it will be found of 
great service. A fermenting poultice to be well made 
requires at least twelve hours to prepare, in order 
that the process of fermentation may have thoroughly 
extended itself throughout the mass. 

The Mustard Poultice is prepared by mixing 
flowers of mustard with water, to the consistence of 
that which is commonly employed for the table, and 
then spreading it very thinly on muslin, allowing it 
to remain on the part only till it reddens it, be it 
five or fifty minutes. The vinegar with which the 
mustard is sometimes mixed, so far from increasing 
its powers of stimulation, materially weakens them. 

Narcotic Poultices, or those containing opiates, 
as poppyheads, or powdered opium, &c, will some- 
times prove very serviceable, and may be made by 
the addition of any of these substances to an Emol- 
lient Poultice. 

To confine a poultice to a part, some of the ban- 
dages or handkerchiefs hereafter mentioned may be 
employed, at the option of the surgeon. 

Plasters are made of various substances, and are 
occasionally employed to soften indo- 
lent tumours, procure their resolution, Fi 9- 26 - 
or hasten their suppuration. In their 
preparation the surgeon has no part, 
as this properly belongs to the apothe- 
cary. He may, however, be required 
to direct the shape of them, in order 
to ensure their more accurate appli- 
cation. In general, nothing more is 
5* 




54 PREPARATION AND 

necessary to adapt a plaster to a part than to slit 
the angles which project when the plaster is applied 
to the surface. But in the plaster for the female 
mammae a peculiar shape is required, which may be 
best obtained thus: — Fold a piece of paper on itself, 
so as to form a perfect square of the size required ; fold 
this so as to make an oblong square ; double it and 
fold its angles so as to make a smaller square; fold 
this into a triangle, and round 
off its upper angles as in the 
dotted line (Fig. 26). Then cut 
off semicircularly as much of the 
point as will make an opening 
large enough to admit the nipple, 
or more if desired, and slit the 
sides at the circumference for 
one inch towards the centre. 
This when opened out will give 
the figure required (as in Fig. 27), and will enable 
any one to spread a plaster of a proper shape. 

Irrigation, or the water-dressing, is the term ap- 
plied to certain dressings which are intended to keep 
parts constantly moist, and thus diminish an excess of 
inflammatory action. In simple erysipelas of some 
extent ; in phlegmonous erysipelas ; in compound frac- 
tures ; in sprains ; dislocations, and other injuries to 
joints ; and in cases of sloughing from excessive action, 
as after amputations, they afford a most excellent 
means of combatting inflammation. In order, however, 
that irrigation may be most advantageous, consider- 
able care and attention is requisite on the part of the 
nurse in its application, as well as judgment on the 
part of the practitioner, in selecting warm or cold 
water. Whichever is used, it is a matter of some 
importance to keep up a constant supply of the 
liquid, for if the stream is not kept up steadily 
there will be a constant change in the temperature 
of the part, and a reaction from cold to hot, or the 



APPLICATION OF DRESSINGS. 55 

reverse, which will do harm by exciting an increased 
circulation in the part. There may, also, be too 
great a degree of cold, or the patient become wet 
with the dressing, or suffer from cold in some in- 
ternal organ, &c. As illustrative of the marked 
advantages of irrigation by cold water in the treat- 
ment of numerous injuries, I would here cite the 
following cases reported by Mr. Gilchrist, of Aber- 
deen, in the British and Foreign Medical Review, 
for July, 1846. 

" 1st. A man received an injury by the machinery 
in a large paper-mill, which laid open the wrist-joint. 
The hand was half separated from the forearm; the 
tendons were torn, and the inferior end of the radius, 
which is naturally related to the carpus, was exposed ; 
the arm and hand were placed straight upon a pillow, 
the wound was cleaned, and two stitches taken ; a 
pledget of cloth soaked in cold water was applied, 
and a bandage rolled, not too tightly, round the hand, 
wrist, and forearm ; a large basin of cold water was 
placed conveniently by the bed-side, and directions 
left to apply freshly-soaked cloths over the bandage 
every two or three minutes, to prevent any heat or 
inflammation ensuing. No inflammation took place ; 
the modelling process was uninterrupted, by sup- 
puration, and an excellent cicatrix formed in little 
more than a fortnight. 

" 2d. A girl had the whole of the soft parts on the 
palmar surface of the four fingers as it were scraped 
off by the machinery in a flax mill ; the tendons were 
torn, and the phalanges exposed at different places. 
Each finger was dressed as follows every day : being 
first bathed in cold water, a piece of soft cloth was 
placed round the finger, and a narrow roller to keep 
it applied; when the fingers were all thus dressed, a 
larger cloth soaked in cold water was wrapped round 
them together, and changed as frequently as it 
showed the slightest tendency to become heated. 



56 PREPARATION AND 

The modelling process advanced steadily without 
suppuration, and cicatrisation was completed in 
about four weeks. The fingers gradually acquired 
flexibility. 

"3d. A little boy had scrofulous disease of the 
bones of the ankle-joint, on account of which I am- 
putated, by the flap operation, below the knee. Two 
stitches were used for two days ; a strip or two of 
plaster, and cloths wrung out of cold water, were the 
sole applications. The wound was whole in a week. 
Other amputations have been similarly treated, with 
equal success. 

" 4th. A girl received a sharp instrument in the 
ball of the eye at the Woodside works. The cornea 
and sclerotic coat were ruptured ; the iris was lacer- 
ated, and prolapsus followed. Rest in bed; con- 
tinued persevering use of cloths wrung out of cold 
water, and simple laxative medicine constituted the 
treatment. The treatment was effectual in prevent- 
ing inflammation, which was clearly the only indica- 
tion in the case. The termination was as favourable 
as it could be, under the circumstances." 

These cases are strong arguments in favour of this 
simple and ancient remedy, and might be supported 
by numerous others, of a similar kind, that have fallen 
under my own observation, did it seem necessary. 
I will only, however, now mention a few instances 
where much benefit maybe gained from the use of cold 
water, and in which the popular tendency to Hydro- 
pathy, at present existing, may be most usefully 
directed by the surgeon in the scientific treatment 
of many of the injuries daily coming under his notice. 
Thus, a stream of cold water from a pitcher or syphon 
will be found highly serviceable in acute as well as 
chronic sprains ; in false anchylosis ; stiffness of 
muscles after fractures; chronic indurations and 
glandular enlargements, &c, &c. ; whilst the reco- 
veries after amputations, when the cold-water dress- 



APPLICATION OF DRESSINGS. 57 

ing has been used, have been such as have proved 
highly satisfactory. 

The simplest form in which Irrigation either with 
hot or cold water can be properly arranged, is that 
shown in the cut. (Fig. 28, A B and C.) 

Fig. 28. 




The limb to which it is to be applied is first laid 
upon a piece of oil cloth or coach-curtain, to prevent 
the wetting of the bed and clothes of the patient. 
This is to be bent on the outer side, so as to form a 
little gutter to carry off the water, after it has gone 
on the limb, into the vessel placed below. Then a 
pan filled either with cold water, cold lead-water, or 
other cold or hot lotion, should be placed near the 
bed at such a height as will be most convenient, and 
from it strips of patent lint twisted together; or, 
what is better, a piece of cotton-wick, as A and B, 



58 PREPARATION AND 

made to extend to another piece of lint covering the 
part affected. The wick, previous to its application, 
being wet absorbs readily the fluid in the basin, or, 
in other words, forms a Syphon. 

Another mode of irrigation, which is rather neater, 
is by means of a tube with a cock, arranged as in the 
same cut at C. This may be made at a moment's 
notice by any tin-plater, or extemporaneously, of a 
piece of cane-angle and some quills. 

In either case, if the patient complains of the cold 
or heat, it is easy, by means of the cock, or by plugs 
of wood introduced into the quills, to regulate the 
amount of fluid which shall pass over. But this is 
the only advantage which the latter apparatus pos- 
sesses over the syphon, while the simplicity of the 
latter, and the facility with which it may be made 
and applied, recommend it strongly to favour. 



RULES FOR DRESSING. 

It will now be seen, that as the different articles 
employed in Dressing are very varied, and the cases 
to which they are applicable equally so, it must be 
a difficult matter to give special directions as to their 
employment. Nevertheless, there are certain rules 
founded on common usage, and such as experience 
has tested, that will be found advantageous to the 
young dresser, by enabling him to anticipate difficul- 
ties for which he would otherwise be unprepared. 
Thus, the choice of the position of both surgeon and 
patient; the selection of assistants; the order in 
which the different articles are to be employed, &c, 
may readily be reduced to general laws ; whilst the 
modifications required for particular cases can be 
treated under special heads. 



APPLICATION OF DRESSINGS. 59 

Before proceeding to any dressing or operation, it 
is important that every step of it should be antici- 
pated in order that nothing may be wanting. Proper 
assistants should also be ready, and each of them 
made fully to understand the duties that he will have 
to perform. Especially is this necessary in the treat- 
ment of cases in private practice, where the surgeon 
is often obliged to take his assistants from among the 
friends of the patient. These, from a desire to aid, 
are generally very ready and willing to perform 
whatever may be asked of them ; yet when actually 
engaged, become faint, sick, hurried, or otherwise 
unfitted for duty, in consequence of some peculiarity 
of system, or from want of habit. Even medical 
men will thus occasionally be thrown out of service, 
as very many are sickened by a bloody operation, 
or disgusted by a simple dressing, accompanied only 
by the smell of unhealthy pus, &c. As every surgeon 
has frequently experienced this even in very simple 
cases, all will readily admit that the selection of 
assistants is a matter of the first importance. 

The observance of the following rules in regard 
to dressing will be found to add very materially to 
the comfort both of the patient and surgeon. 

1st. Let the surgeon make, or see made, every- 
thing that is requisite for the new dressing before 
removing the old one. 

2d. Let him have a sufficient number of capable 
aids, to whom special duties shall be assigned before 
commencing the dressing, as this prevents confusion. 
Thus, in dressing a stump, or wound, there should 
be one assistant to support the limb ; another to fur- 
nish hot water, and change it as required ; heat the 
adhesive strips, hand cerate, &c, &c, by which 
means the surgeon can give his attention wholly to 
his own duty. 

3d. Let him arrange the bed, as a general rule, 
after the dressings are changed ; or, if in a case of 
fracture, before the patient is placed on it. 



60 PREPARATION AND APPLICATION OF DRESSINGS. 

4th. Let the position of the patient be such as will- 
cause him no unnecessary fatigue. 

5th. Let the surgeon, as a general rule, place him- 
self on the outside of the limb with his face to the 
patient, as this will give more freedom to his move- 
ments, and prevent accidental jars. 

6th. Let all the assistants be especially careful to 
guard against hasty and inconsiderate movements, in 
order to prevent unnecessary pain to the patient. 

The other duties of assistants in dressing or opera- 
ting will be treated under the head of Minor Opera- 
tions, Part Fifth. 



CHAPTER II. 

OF THE PREPARATION AND APPLICATION OF THE 
BANDAGE. 

By Bandaging is generally understood the confine- 
ment in their proper situation, of dressings or other 
surgical apparatus, by means of pieces of muslin. 

The term Bandage, in its strict signification, is 
only applicable to a collection of bands, or to such 
pieces of stuff as are fastened to one another and 
employed as a whole ; though general usage now jus- 
tifies its application to the single strip or Holler. 
This roller is generally a band of flannel, linen, mus- 
lin, calico, cloth, gum- elastic, or other substance, oi 
different lengths and widths, rolled upon itself into 
a firm mass, so as to render its application to any part 
of the body more easy than it would be if simply folded 
up. As most generally seen, the roller is formed of 
muslin, eight or ten yards long; one-half, two, two 
and a half, three, or four inches wide, free from hems 
or darns, soft, pliable, and unglazed, to prevent its 
slipping. As thus made, bandages may be divided 
into two kinds : — 1st. Simple, or those formed by the 
application of the roller only; and 2d. Compound, 
or those resulting from the complex arrangement of 
the pieces composing them, as in the double T, 
sling, &c. 



OF THE SIMPLE BANDAGE, OR ROLLER. 

The Boiler is to be prepared from a piece of mus- 
lin of the requisite length and width, by tearing it 
from the piece and then winding it into a cylindrical 
6 



62 



PREPARATION AND 




form, either by a machine, or by the hand, so as 
to form one or two masses, and constitute what 
is called a Single or Double-headed Roller. A 
machine for rolling bandages, one of Dr. Barton's 
earliest contributions to Surgery, is seen in Figure 

29, and may well serve 
as a pattern for others, 
as its adaptation to the 
purpose has been long 
tested and found satis- 
factory. It consists of 
a base A, and of two 
uprights, B B, in which 
runs a spindle, G, to 
receive the bandage; a 
broader upright, C, to 
support a moveable frame, F, which, by its pressure, 
tends to tighten the bandage, D D, as it is rolled, 
and of a screw, E, to fasten the machine to a table. 
Various other machines, modified to suit peculiar 
views, are used by other surgeons, and thought to 
possess peculiar advantages ; but the principle of all 
is the same. When, in hospital practice, it is de- 
sirable to economise material, and re-apply a bandage 
several times, the use of a machine like that which I 
introduced into the Pennsylvania Hospital in 1837, 
will be found advantageous. It consists in a machine 
like Fig. 29, with the addition of two hollow steel 
cylinders between which the bandage is passed as it 
winds on the spindle. These cylinders, receiving a 
hot iron in their centre, smooth the bandage as it 
passes between them. 

In rolling a bandage on any of these machines one 
extremity of the band should be wrapped around the 
spindle, and wound up by turning the handle with one 
hand and directing the course of the band with the 
other, so as to ensure its being wound evenly. Then 
seizing the roller firmly, reverse the action of the 




APPLICATION OF THE BANDAGE. 63 

spindle ; draw it out of the cylinder and tear off all the 
loose threads, as they will not then unravel much if 
the cylinder is tightly rolled, but will, if left, retard 
its application. If the threads are torn from the 
strip before it is formed into the cylinder, a large 
portion of the stuff will be wasted in ravellings. 

Thus formed, the Single-headed Roller consists 
of two extremities ; of an initial 
or free end ; of a terminal one, Fi 9- 30 - 

or that found in the centre of 
the cylinder; of two surfaces, 
an external and an internal, 
and of a body, or portion be- 
tween the two extremities. 

The Double-headed Roller has the same parts 
as the single one, except the initial end, which is 
wanting, in consequence of both ends being here 
wrapped into cylinders. The application of this 
roller, therefore, always commences with its body. 

With a machine at hand, there 
can be no reason wiry every sur- ___ ' 
geon should not keep himself well 
supplied with bandages. But as 
a necessity sometimes occurs for 
the re-application of the same 
roller, both from economy and convenience, or from a 
surgeon being accidentally unprovided with a roller, 
he should early accustom himself to the manufacture 
of a bandage without using the machine. In order to 
do this with the greatest ease the following directions 
will be found serviceable : — Fold the terminal end of 
the band five or six times on itself, so as to form a sort 
of axis, and roll it a few times on the thigh to give 
it size. Then place the cylinder between the thumb 
and forefinger of the left hand; allow the body to 
run over the right forefinger, seizing it firmly be- 
tween the thumb and finger of that hand so as to 
make traction, and tighten the cylinder. Having thus 




64 PREPARATION AND 

arranged it, give a rotatory motion to the band, and 
cause the cylinder to revolve upon its axis by means 
of the fingers and thumb of the left hand, whilst, at 
the same time, the right thumb and forefinger revolve 
partially around the cylinder itself, which, by this 
compound movement, is soon formed as required. 

Fig. 32 shows the position very well, and will ex- 
plain the directions just given, simply by looking at it. 

Fig. 32. 




After a very little practice a student will find it an 
easy matter thus to roll a bandage with either hand 
almost as quickly and tightly as it can be done on 
the machine, although at first the movements will 
seem to be very awkward. 

When a roller is intended for the body it should 
be twelve yards long and about four inches wide ; 
when for the head, five yards long by two inches wide ; 
when for the extremities, eight yards in length, and 
two, two and a-half, or three inches in width, accord- 
ing to the size of the limb, the thigh requiring a 
roller to be a little wider than that used for the leg. 

In order to apply the single-headed roller to any 



APPLICATION OF THE BANDAGE. 65 

part of the body it should be held between the thumb 
and fingers of either hand, and pressed by the fin- 
gers firmly against the palm, so as to prevent the 
cylinder from slipping out of the hand as it unrols, 
which it is apt to do if held so that its internal sur- 
face would be the part first applied. Or, it may be 
held by placing the thumb and first and second fingers 
of either hand on the two extremities of the cylinder. 
In either case, the external surface of the free end 
must be the portion first applied to the part, and this 
should be retained there by pressure of the fingers 
until one or two turns are made round the part so 
as to fix it firmly; after which the roller may be car- 
ried up the limb. 

Bandages have been divided into several kinds, 
either according to the direction which they take in 
covering the part; or from the object to be attained 
by their application. Thus, we have the Circular, 
Oblique, Spiral, Figure of 8, Spica, and Recurrent, 
of the first kind, and the Uniting, Dividing, Com- 
pressing, Expulsive, Retaining, &c, of the second. 

A Circular Bandage is one formed by horizontal 
turns of a roller, each of which overlaps, or very 
nearly overlaps, the one which preceded it. 

In the Oblique, the turns gradually ascend the 
limb, or pass obliquely to its axis. 

In the Spiral they mount still more; the Spica 
forms a figure like the leaves of corn, and in the 
Recurrent, the folds run back to the point whence 
they started. 

The Uniting Bandage is named from its action, 
and is that which is used to bring together the edges 
of wounds. It should be adapted to their direction 
according as they take a longitudinal or transverse 
course, and will be again referred to under the treat- 
ment of wounds. 

The Dividing Bandage is one which is used to 
prevent the formation of cicatrices, as in the treat- 
6* 



66 PREPARATION AND 

raent of burns, or of wounds, attended with great loss 
of substance. 

The Compressing Bandage is the name given to 
any bandage which is employed for exerting com- 
pression, as in oedematous swellings, callous ulcers, 
varices, aneurisms, &c. 

The Expelling Bandage is employed in the treat- 
ment of deep-seated abscesses, fistulse, contused 
wounds, &c. It is usually a roller applied over com- 
presses, upon the region wherein the matter to be 
expelled is placed, and acts by preventing these fluids 
from travelling along the interstices of the mus- 
cles, &c. 

Retaining Bandages are those which serve to 
confine dressings and displaced parts in their proper 
situation, examples of which are seen in those used 
in the treatment of fractures and dislocations. 

The necessity which so often presents itself of 
applying to the different parts of the body some of 
the bandages just referred to, has rendered the 
study of bandaging one of the important points of 
a student's education ; yet, from its having been too 
generally overlooked, it not unfrequently happens 
that a practitioner finds himself in charge of a 
case, requiring considerable skill in dressing, before 
he has gained as much dexterity as would be pos- 
sessed by any good surgical nurse. If, then, it is 
deemed desirable to avoid mortification, or if he 
wishes to perform a duty in the manner that its im- 
portance deserves, every student will at once take a 
roller in hand and exercise himself until he has ac- 
quired such manual skill as practice alone can 
furnish. 

Any bandage which does not give perfect support 
to the parts, maintain them in the position necessary 
to ensure the fulfilment of the indication proposed, 
or exert on the member an equable compression, is 
useless, or worse than useless, as it may produce 



APPLICATION OF THE BANDAGE. 67 

such a state of things as will eventuate in the loss 
of the limb, or even of life ; and this loss should rightly 
be charged to the defects of the medical attendant. 
Their proper application is, therefore, a matter of 
great importance. 

In no department of surgery, says Dr. Hennen, 
" will the reputation of a young practitioner be more 
seriously involved than in that referring to the ap- 
plication of the bandage. Our young surgeons may 
study, philosophise, and reason well, but neither 
books nor reflection, nor arguments, will teach the 
application of a bandage without repeated practice." 
Practice alone can give the dexterity which is so 
necessary for its proper employment ; and unless a 
bandage is proper applied, it had better be omitted ; 
for if too loose it will not fulfil its indication ; and 
if too tight may produce gangrene." 

The practitioner's reputation is also liable to con- 
siderable injury, as he will be sure to suffer from the 
judgment of those around him, if he shows ignorance of 
this important duty. The majority of persons, says 
Hennen, "are ever attentive to the manipulations of 
any workman, and can soon judge, and judge cor- 
rectly, whether or not he is acquainted with his 
business ; consequently they do not hesitate to exer- 
cise their criticism to its fullest extent, in the case 
of the surgeon ; and when their opinion of his ignor- 
ance is confirmed by the patient's continued suffering, 
they are ever ready to disseminate it widely." On 
the contrary, when a bandage lays smooth and regu- 
larly on the limb, when the patient is relieved from 
previous torture, and the part assumes the neat ap- 
pearance that always follows the visit of an expe- 
rienced dresser, the confidence of friends is raised, 
and his subsequent visit is looked forward to with 
confident anticipations of relief. 

Surgeons who, from want of practice, cannot pro- 
duce the neat appearance of a well-applied bandage, 



68 PREPARATION AND 

are frequently induced, in order to escape the remarks 
so often made on this point by those around the 
patient, to resort to the wetting of the roller, in 
order to cause it to adapt itself more readily to the 
part. But this practice should never be permitted 
except in the treatment of Dislocations, unless we 
would wish to expose a patient to the risks of morti- 
fications, as it is impossible for any one to calculate 
how much a wet roller will shrink in drying, and 
consequently how great a degree of pressure it will 
make on a part after we have left it. A bandage 
may be of the proper degree of tightness at the 
time, the patient make no complaints, and yet in 
three or four hours be suffering such agonies as 
must be seen or felt, to be properly appreciated. 
The question, then, may very properly be asked, 
as to how much traction should be made in order 
properly to apply a roller. To a certain extent 
this must depend on the object to be attained 
in its application, as a bandage which is merely in- 
tended to confine a dressing need not be as tight as 
one that is used to compress muscles. But, as a 
general rule, a bandage is not too tight if the pa- 
tient feels easy under it two or three hours after 
its application. Until then practice has taught the 
practitioner the degree to which a roller should be 
drawn, the fact must be recollected, that one which 
is too tight will do serious injury, while all that can 
result from one that is too loose will be the non-ful- 
filment of the indications for its application. The 
young surgeon had, therefore, better guard against 
the first evil, as repeated evidence has shown that the 
tendency of all young dressers is to use too much 
traction on a bandage, and not too little. In order 
to learn the proper degree of tightness, it is only 
necessary to practice on a friend, or, what is better, 
allow that friend to practice on us, when the suf- 
fering that will be inflicted by his want of skill will 
doubtless prevent the lesson being soon forgotten. 



APPLICATION OF THE BANDAGE. 



69 




In the consideration of the special application of 
the roller, I shall take up — 1st, its application, ac- 
cording to the course which it takes around the part ; 
and 2d, that resulting from the object to be attained 
in its application, commencing with the head and 
proceeding regularly to the toes. 

The Circular Bandage is that, as has been said, 
in which each turn over- 
laps the one that preceded 
it, so that the whole ban- 
dage looks like a single 
turn, and runs directly 
round the part. (Fig. 33.) 
All the circular bandages 
are very simple, and con- 
sist of, one for the Fore- 
head, in which the turns encompass the vault of the 
cranium ; one for the Eyes, to retain dressings to 
these organs ; one for the Neck, as in the dressing 
of blisters, setons, &c. ; one for the Arm, as in the 
compression of the veins previous to bleeding ; and 
a few of a like nature for other parts of the body. 

In the confinement of the terminal end of a circu- 
lar, or any other bandage, two means are employed : 
1st, the use of pins ; 2d, the employment of little 
bands tied in bow-knots. 

When pins are used, they should be placed either 
in the direction of the length or 
breadth of the band. If in its length, 
the head should always be turned from 
the free end of the roller (Fig. 34), 
otherwise the tendency of the roller 
to become loose, and the constant 
drawing against the pin, will at last 
withdraw it entirely. On the other 
hand, if the pin is applied trans- 
versely, the head should always pre- 
sent to the upper extremity of the limb, in order to 




70 



PREPARATION AND 




prevent the point from sticking in the fingers of the 

surgeon when his hand 
is passed down the part, 
either in smoothing the 
turns of the roller or in 
seeking for the end of 
the bandage in its re- 
moval. (Fig. 36.) A re- 
ference to Fig. 35 will 
show how the pin may be drawn out by the unwind- 
ing of the roller itself. Some surgeons prefer fas- 
tening the end of a roller by means of a piece of tape, 
or by slitting it for a short distance into two strips 
and tying the pieces in a bow-knot (Fig. 37) ; but 
this fastening is seldom as neat or firm as the pin, 
except when bandaging fingers or toes. In these 
portions of the body it will be found to be rather 
more convenient. 

The Oblique Bandage differs from the circular, 
in its turns being made less at right angles to the 
axis of the limb, in consequence of which the roller 

can be made to cover a 
greater extent of sur- 
face, as each turn passes 
a little beyond the one 
previously made, and 
follows a course which 
leaves a considerable 
space between the turns. 
The oblique bandage is 
chiefly employed in re- 
taining dressings, although occasionally useful, espe- 
cially when conjoined with other bandages, in cases 
which will be treated of hereafter. 

The Spiral Bandage is that which is most fre- 
quently employed in the treatment of all affections, 
whether of the extremities or trunk. Its turns as- 
cend the limb less rapidly, are closer together, and 




APPLICATION OF THE BANDAGE. 



71 



cover the part much more firmly than the oblique, 
thus making a certain amount of pressure in addi- 

Fig. 38. 




tion to the retention of the dressing. Each turn of 
the spiral bandage should cover in at least one-third 
of the preceding turn ; and as most of the parts to 
which it is applied are conical in their shape, espe- 
cially in the extremities, it follows that in ascending 
from the lower to the upper portion of them we must 
pass from the apex of the cone to its base, and that, 
consequently, one edge of the roller will press on the 
limb, while the other will project from it so as to 
make the openings designated as Gaps, as seen at 
a, b, c (Fig. 39). To obviate this, and cause the 
bandage to apply itself more perpendicularly to the 

Fig. 39. 




whole surface of the part, or, in other words, to equal- 
ize the pressure, the roller must be half folded on 



72 PREPARATION AND 

itself, or a doubling made, which is called a Reverse ; 
and as the bandage by this action acquires an in- 
creased thickness, a greater degree of pressure will 
be made on the reversed points than at any other. 
It is therefore desirable, in order to obviate the welts, 
and other bad effects occasionally resulting from these 
reverses, that the turn should be made as short and 
smooth as possible. To make a reverse is, there- 
fore, a matter of much importance, and constitutes 
the first difficult step in bandaging ; not that there is 
any real difficulty in the manoeuvre, but simply, I 
think, because sufficient attention is not generally 
paid to its mechanism. The following rules, which 
constant practice and extended experience have es- 
tablished, will render the matter perfectly simple ; 
and if observed, not only make the formation of a 
reverse very easy, but also make it almost impossible 
to prevent its proper formation : 

Rules for making Reversed turns. — 1st. Hold the 
roller in the position in which it is generally ap- 
plied, that is, either by its body or its two extremities, 
the hand being in a state of supination. 2d. Apply 
the initial extremity to the limb, and continue to make 
simple spiral turns until you approach the enlarged 
portion of the limb. 3d. Apply a finger of the free 
hand to that portion of the bandage which is already 
in contact with the limb, not to assist in forming the 
reverse, or to fold it down, but simply to prevent 
the turns already applied from slipping or becoming 
relaxed while the reverse is being made. 4th. See 
that no more of the bandage is unrolled than will 
enable you to separate the cylinder a short distance, 
say four or six inches from the limb. 5th. Keep that 
portion of the bandage which is between the finger, fix- 
ing the body of the roller and the cylinder perfectly 
slack. 6th. Turn the hand holding the cylinder from 
supination into decided pronation, by a simple motion 
of the wrist alone, without moving the fingers from 



APPLICATION OF THE BANDAGE. 73 

the cylinder, as shown in (Fig. 40), taking especial care 
to make no traction, nor to sink the cylinder below 

Fig. 40. 




the level of the limb till the fold or reverse is made, 
when it may again proceed up the limb, it being recol- 
lected that each turn should ascend spirally, and only 
cover in about one-third of that which preceded it. 
7th. Keep each turn and each reverse parallel with 
its fellow. 

As these reverses are indispensable wherever there 
is an increase in the size of the part, as from the 
development of muscles, &c, it is of the greatest im- 
portance that the proper way of making them should 
be acquired, as no spiral bandage can well proceed 
six inches on an extremity without requiring their 
formation ; and although they are generally regarded 
as the most difficult point in the application of the 
roller, a little attention to the rules just given, espe- 
cially to that which requires that no traction should 
be made, nor the cylinder sunk below the limb, or 
widely separated from it whilst the reverse is being 
formed, will enable any one after a little practice to 
make them with great ease and neatness. To add 
to the latter, all the reverses should, as far as possi- 
7 



74 



SPTRAL BANDAGES. 



ble, be kept in a perpendicular line, as seen in the 
cut of the spiral of the lower extremity, and this will 
always result without extra attention, from the ob- 
servance of the direction to keep the edges of each 
turn parallel. I repeat that the difficulties expe- 
rienced in making reverses, and the terrible, twisted, 
and corded things, sometimes made for reverses even 
by those who are good operating surgeons, are always 
the result of traction on the bandage, while the re- 
verse is making. 

The special applications of Spiral Bandages are 
as follows : first, 

THE SPIRAL OF THE CHEST. 

The application of this requires a single headed 

roller ten ort welve 
Fig. 41. yards long and three 

or four inches wide, 
and that the patient 
should be sitting in 
such a position as will 
enable the surgeon to 
pass the roller readily 
behind his back. In 
applying the bandage, 
place the initial ex- 
tremity on the ante- 
rior part of one axilla, 
say the left, and con- 
duct the roller upwards across the front of the chest. 
Pass over the right clavicle and the back, to the 
point of departure, similar turns being thus made 
until there is formed one or two obliques of the 
neck and that axilla whence it started. Then carry 
the roller across the front of the chest to the right 
axilla, and form an oblique of this axilla and the left 
clavicle ; after which, carry it firmly around the chest 
in spiral turns from above downwards, drawing each 




SPIRAL BANDAGES. 



75 



turn with firmness, so as to compress the ribs, and 
oblige the patient to breathe by the diaphragm and 
abdominal muscles. 

Use. — In fractures of the ribs or of the sternum, 
care being taken to apply compresses to their ante- 
rior and posterior extremities, if the fragments pro- 
ject inwards ; but if the deformity is angularly out- 
wards, place a compress only upon the projecting 
point. It is sometimes useful if the patient, from 
mania a potu or other causes, should be very restless, to 
add to this bandage the T bandage for the body, shown 
hereafter, in order to prevent the roller from slip- 
ping ; but, generally, the oblique turns of the neck 
and axilla will answer this purpose. 



THE SPIRAL OF THE ABDOMEN 

Is formed of the same kind of bandage as the above ; 
but in its application we should commence at the 
lower part of the chest and carry the roller spirally 
round the abdomen from above downwards, adding 
to it a single T, or making one or two oblique turns 
around the thighs to prevent its slipping upwards. 

Use. — To compress the abdomen, as in certain 
cases of tympanitis, or after 
the operation for tapping -%• 42 - 

in ascites. But its place 
may be well supplied by a 
double T of the abdomen, 
when firm pressure is not 
required. 

THE SPIRAL OF THE PENIS 

Requires a bandage eigh- 
teen or twenty-four inches 
in length, half an inch 
wide, and slit into two 
pieces at its terminal extre- 




76 SPIRAL BANDAGES. 

mity. Then commencing at the glans penis, form an 
ordinary spiral which shall terminate at the root of 
the penis, and be confined there by tying the two ends. 
(Pig. 42.) 

Use. — This is chiefly employed to retain dressings 
to the penis in cases of chancres and other sores 
external to the prepuce. It has also been used in the 
treatment of gonorrhoea, in order to compress the ure- 
thra, a catheter being left in it ; but it is very apt 
to produce erections, which do harm, and quickly 
derange the bandage. The sheath of the penis, spoken 
of hereafter, answers better in many instances, and 
especially in gonorrhoea. 

THE SPIRAL OF THE UPPER EXTREMITY 

Requires a roller eight yards long, two or two and 
a-half inches wide, and compresses, if it is to be used 
to make pressure on particular parts, and aGt as a 
Compressing Bandage. In its application, having 
covered in the fingers, if necessary, by the gauntlet, 
as shown hereafter, commence with one or two circu- 
lar turns around the wrist, in order to fix the end of 
the bandage ; then pass obliquely over the back and 
palm of the hand to reach the extremities of the 
fingers, and ascend by three spiral turns without re- 
versing, until the phalangeo-metacarpal joint of the 
thumb is reached ; cover this and the wrist-joint by a 
figure of 8, such as is described hereafter, and ascend 
the limb by simple spiral and reversed turns till we 
reach the elbow. Cover this also by a figure of 8, 
if the arm is to be flexed ; if not, by simple spiral 
turns without reverses, and continue the spiral and 
reverse turns to the shoulder, placing compresses, &c, 
where they may be required (Fig. 43). 

This bandage is daily used to cover in, support, 
and compress the arm, as in varicose veins, aneuris- 
mal tumours, treatment of fractures, &c, and is with 



SPIRAL BANDAGES. 77 

the exception of the turns for the elbow perfectly 

Fig. 43. 




easy. Attention to the figure of 8 bandages will soon 
overcome the latter difficulty. 

Its effects, when well applied, are excellent ; but 
it may become very fatiguing and painful if drawn 
tight, and if too tight may produce gangrenous ulcer, 
&c. In 1837, it was found necessary in the Penn- 
sylvania Hospital to amputate the forearm of a man 
who had only a simple fracture of the lower extre- 
mity of the radius, but whose arm was gangrenous 
from the mal-application of this bandage by an igno- 
rant surgeon. 

THE SPIRAL OF THE FINGER 

Is composed of the roller known as the finger band- 
age, which is only one inch wide, of the requisite 
length, say one yard, and split into two ribbons at 
its terminal extremity. 

As the spiral turns of this little bandage are em- 
ployed by every one to retain dressings to the finger 
in cases of wounds, it may seem unnecessary to offer 
any directions for its application ; but without a turn 
round the wrist it is very apt to become deranged. 
7* 



78 



SPIRAL BANDAGES. 



To prevent this it should always be applied as 
follows : — Fix the initial extremity round the wrist 
by a circular turn, and cross the back of the hand, 
in order to descend either finger to its extremity by 
very oblique turns. Then commencing at the extre- 
mity make an ordinary spiral with reverses, and 
terminate the bandage either by a knot on the fingers, 
as seen in Fig. 37, or with a few circular turns round 
the wrist. 



THE SPIRAL OF ALL THE FINGERS, OR GAUNTLET, 

Requires a band, eight yards long and of the preced- 
ing width, rolled into a 
Fig. 44. cylinder. Then commence, 

as before, by one or two 
circular turns around the 
wrist ; pass obliquely over 
the back of the hand, and 
descend by oblique turns 
to the nail of the fore- 
finger, after which ascend 
by spiral and reversed 
turns to its base; pass to 
the middle finger; descend 
by oblique turns to its nail ; 
ascend by spirals to its 
base, and so on, till all the 
fingers are covered, ter- 
minating at the base of the 
little finger. Then pass 
in front or on the back of 
the hand, to finish by cir- 
culars around the wrist. 
The last turn in the cut is represented as much too 
wide ; those on the fingers and hand are more cor- 
rect. 

Use. — We may resort to this bandage when more 
than one finger is injured, and there is reason to fear 




SPIRAL BANDAGES. 



79 



their uniting if they are permitted to come in con- 
tact, as in cases of burns. If there is a necessity for 
retaining dressings at the metacarpal extremities of 
the fingers, or at the interdigital spaces, we may add 
to this the Demi-Gauntlet, Double T of the Hands, 
or the Perforated T, as hereafter shown. 



THE DEMI-GAUNTLET 



Is formed of the same pieces as the preceding, and 
applied by making a few 



circular turns around the 
wrist, and then passing 
across the back or palm 
of the hand, as the case 
may be, by oblique turns 
which will pass from the 
root of each finger, or its 
interdigital space, to make 
a circular turn round the 
wrist (Fig. 45). 

This very light band- 
age is chiefly useful in re- 
taining dressings on the 
front or back of the hand. 
But its place may be sup- 
plied by the perforated T, 
or the double T of the 
hand, under certain cir- 
cumstances. 



Fig. 45. 




As the Spiral of the Thigh, of the Leg, of the Foot, 
and of the Toes, resemble each other, they may all 
be included in 



THE SPIRAL OF THE LOWER EXTREMITY. 

This requires two rollers, each eight yards long 



80 SPIRAL BANDAGES. 

and two and a-half inches wide, and that the patient 
be seated with the extremity of his heel on the very- 
point of the surgeon's knee, or else, lieing down, 
with the leg supported by assistants. The surgeon 
being either at the foot or on the outside of the 
limb, and either sitting or standing, commences by 
making one or two circular turns from without in- 
wards, immediately above the malleoli, in order to 
fix the end of the roller. He then descends, if in 
the right foot, from the external malleolus obliquely 
across the instep and under the sole to the extremity 
of the little toe ; from this he makes two or three 
oblique turns upwards so as to cover in the foot as 
far as the instep, and then covers in the heel by turns 
of the figure of 8, one extremity of the eight embrac- 
ing the heel and ankle, the other the instep. After 
this he ascends the limb by spiral reversed turns, 
made with either hand, until he reaches the knee; 
this joint being covered in by a figure of 8, he then 
proceeds with the second roller to make spiral re- 
versed turns on the thigh, till the whole limb is 
covered. 

Use. — This bandage, if well applied, fulfils every 
indication that can be required of a bandage in frac- 
tures, ulcers, varicose veins, or oedema, and will 
usually keep its place for two or three days without 
being renewed, if the patient remains in bed. The 
main difficulty in its application consists in the cover- 
ing of the heel. This is not, however, absolutely neces- 
sary, as in many cases the close adhesion of the integu- 
ments to the parts below prevents any great amount 
of swelling ; but where a considerable degree of com- 
pression is to be made on the leg, as in the treatment 
of varices, fistulse, &c, it is a better plan to cover 
it. To do this, proceed after the early turns from 
the inside of the instep, say of the right foot, over 
the point of the heel; come up over the outside of 



SPIRAL BANDANES. 



81 




Fig. 47. 



the instep ; down on its inside ; under the sole of the 
heel, folding in the loose 
edge of theprevious turn; Fig. 46. 

then around back of the 
heel to the internal mal- 
leolus; over the front of 
the ankle ; under the sole 
of the instep ; round the 
back of the heel; over 
the external malleolus ; 
in front of the ankle; 
under the instep to the 

outside of the foot, and then up over the front of the 
ankle to the internal malleolus ; 
round the back of the leg to its 
outside, and then up the limb. 
The turns 'on the heel and foot, 
when completed, will resemble 
those seen in Figure 46. The 
advantages of the circular turns 
round the ankle when commencing 
this bandage are, that it gives 
greater firmness and prevents the 
initial end from becoming loose. 
The French surgeons, however, 
usually begin to bandage at the 
toes, and do not cover in the heel, 
and their course may be followed, 
by those who prefer it, by observ- 
ing the rules for the application of 

THE FRENCH SPIRAL. 

This (Fig. 47) is formed by applying 
a roller two and a-half inches wide 
and seven yards long, as follows. 
Place the initial extremity of the 
roller on the outside of the instep, 
say of the right foot, and pass ob- 
liquely across to the ball of the big toe ; go under the 




82 SPIRAL BANDAGES. 

sole to the extremity of the little toe;- and then 
make as many spiral reversed turns as will carry 
the bandage to the front of the ankle, or the front 
of the astragalus. Pass from this around the mal- 
leoli, and ascend the limb by spiral reverses, as in 
the former bandage. The reverses of this and the 
former bandage being the same, are shown in Fig. 
47, the main difference in the two being in the turns 
covering the heel, and in the point of commence- 
ment. 

This bandage is used for the same purposes as the 
ordinary spiral just described, but especially for the 
application of the Dextrine or Starch Bandage, be- 
cause it leaves the toes and heel open to inspection, 
which is all important, and will be again referred to 
in the treatment of fractures. Where it is neces- 
sary to make pressure on the instep, heel, or ankle, 
the Spica of the foot may be added to this (see 
Fig. 62). 



CHAPTER III. 

OF THE CROSSED, OR FIGURE OF 8 BANDAGES. 

These bandages compose some of the best and 
neatest applications of the roller, and are named 
from their shape. As a class they are exceedingly 
useful in covering in joints and other points requiring 
firm and solid compression. They may be made 
either with the single or double-headed roller ; though, 
as the compression resulting from the turns of the 
latter is sometimes very painful and requires watch- 
ing, it is seldom employed in this portion of the 
United States. 



THE CROSSED OF ONE EYE 

Is made of a single-headed roller two inches wide 
and five yards long. 

If the hair is long, cover in the head with a night- 
cap previous to the application 
of the bandage, as this will pre- Fi 9- 48 - 

vent the turns of the roller from 
slipping. Then make two or three 
circular turns round the fore- 
head and occiput, passing from 
right to left if for the left eye, 
and the reverse if for the right. 
On reaching the nape of the neck 
in the third turn carry the roller 
under the ear of the affected side, 
and obliquely up over the jaw 
and injured eye, inclining it well 
to the internal canthus, so as to 
cover the root of the nose, but not so as to affect the 




84 THE CROSSED, OR 

sound eye. Pass hence, across to the temple of the 
sound side ; descend to the nape of the neck, and 
make two or three oblique turns, similar to these, 
terminating the bandage by circular turns around 
the forehead. 

Use. — This bandage answers tolerably well to 
retain dressings to the eye, but is very readily dis- 
placed by the movements of the patient, unless 
pinned fast to the cap first applied. When it is de- 
sirable to make pressure on the ball of the eye, as 
in the treatment of gonorrhoeal ophthalmia, cancer, 
&c, &c, this bandage may prove useful ; but the 
simple circular bandage of the eyes is preferable for 
simple dressings. 

THE CROSSED OF BOTH EYES 

Is made by a single or double headed roller seven 
yards long and two inches wide, with compresses, 
if required. 

In its application, make two or three circular turns 
of the head, turning indifferently from right to left, 
or the reverse ; then on reaching the back of the 
neck pass under the ear of either side, up over the 
eye, root of nose, and parietal protuberance of the 
opposite side, to return to the neck. Make two or 
three turns similar to these, and at the third turn 
pass from the parietal protuberance round the fore- 
head, instead of round the occiput; cross the root of 
the nose, the eye, and cheek of the opposite side 
making an X with the first turns, and proceed in 
oblique turns as before; terminating by circular 
ones. 

Uses. — This bandage, on account of the crossing 
of the turns on the forehead, is much more solid than 
the former, and may be employed in similar cases. 
It will add, however, to its solidity, to cover the 
head, after its application, with a handkerchief or 
nightcap. 



FIGURE OF 8 BANDAGES. 



85 



THE CROSSED OF THE ANGLE OF THE JAW 

Requires a single-headed roller, two inches wide, 
five yards long, and a thick compress. 

In applying it, carry the initial portion of the band- 
age around the forehead, and fix it by two circular 
turns of the vault of the cranium, turning from the 
right to the left and 
backwards, if the disease Fig. 49. 

is on the left side, and 
vice versa. From the 
nape of the neck, direct 
the roller close under 
and behind the ear of 
the sound side ; under 
the jaw to the angle of 
the jaw on the injured 
side, and place the com- 
press behind and on this 
angle. Then carry the 
roller over the compress, 
up over the side of the 

face, between the eye and left ear, obliquely over 
the vertex, and down behind the ear opposite the 
injured side. Make thus three or four oblique turns, 
as seen on the right side of the cut, and terminate 
by circular turns around the forehead. 

Use. — This is an excellent bandage for the treat- 
ment of fracture of the neck and angle of the jaw, 
and the only one that I know of that fulfils the in- 
dications for the treatment of this injury; as it 
forces the angle forward to the anterior portion, 
and counteracts the action of the pterygoid muscles. 
It will, also, be found useful in tumours of the parotid 
region, in retaining dressings to this part. No cir- 
cular turns should be made around the chin and 
neck, as sometimes recommended in the treatment 
of fracture of this part of the jaw, as they tend to 
8 




86 



THE CROSSED, OR 



displace the fragments, and push the chin too much 
backwards. 



Fig. 50. 




BARTON'S BANDAGE, OR FIGURE OF 8 OF THE JAW, 

Is formed by a single-headed roller five yards long 
and two inches wide, the initial extremity of which 

should be placed just below 
the prominence on the os 
occipitis. Then continue 
the roller obliquely over 
the centre of the parietal 
bone ; across the junction 
of the coronal and sagittal 
sutures ; over the zygoma- 
tic arch ; under the chin ; 
and pursue the same di- 
rection on the opposite 
side until you arrive at 
the back of the head. 
Pass them obliquely around 
and parallel to the base of the lower jaw ; over the 
chin, and continue the same course on the other 
side, till it ends where you commenced ; whence it 
runs exactly as before, a pin being placed at the 
vertex. 

Use. — For this beautiful specimen of a bandage 
we are indebted to the skill and ingenuity of Dr. J. 
Rhea Barton, of Philadelphia, a surgeon to whom 
the profession owe many important and novel opera- 
tions, while his skill in the use of bandages is unsur- 
passed by any. Although this bandage may be 
looked on as a small affair compared with some of 
his improvements, yet it is perhaps the one most 
likely to be tried by the generality of practitioners, 
as it is one of the best dressing for fractures of this 
bone, anterior to its angle. In order to apply it 
neatly, the roller should not be over two inches wide, 
and the turns should be made to follow as nearly as 



FIGURE OF 8 BANDAGES. 



87 



possible those which have preceded them, so as to 
give the appearance of but a single turn. 

THE CROSSED, OR POSTERIOR 8 OF THE CHEST, 

Requires a roller five yards long, two and a-half or 
three inches wide, and compresses, tow, or cotton, to 
place on the anterior edge of the axillae in order to 
prevent the bandage from chafing them. Then, 
whilst the patient is sitting with the shoulders well 
drawn back by an assistant, and the compresses are 
held in front of the axillae, carry the initial extremity 
of a roller around the superior part of one arm, say 
the left, and make three or four spiral reversed turns 

Fig. 51. 




from before backwards, and from within outwards. 
From this shoulder pass obliquely over the back to the 
right axilla, the shoulders being well forced backwards. 



88 



THE CROSSED, OR 



Ascend in front of, and over the shoulder ; pass over 
the back to the left axilla ; over the compresses in 
front of this axilla and round to the back ; over the 
back to the right axilla ; over it in front ; and over 
the back to the left axilla. Pass again the same 
course till the roller is nearly exhausted, when it 
may be terminated by circular turns of the body, or 
of the right arm. 

Use. — This bandage will act either as a uniting 
one for the back, or a divisive one for the front of 
the chest, and was formerly much employed in the 
treatment of fractured clavicle. But as its place 
has since been supplied by others which are better, 
it has consequently fallen into disrepute, though it 

Fig. 52. 




may occasionally be a useful addition to the means 



FIGURE OF 8 BANDAGES. 



89 



of treating such accidents, when it is requisite to 
carry the shoulder well backwards. It will also 
prove useful in uniting longitudinal wounds of the 
back, or in preventing contractions from burns, &c, 
on the front of the chest. 



THE ANTERIOR 8, OR CROSSED OF THE FRONT OF THE 
CHEST, 

Is in its action the reverse of the one just described, 

although its composition is the same. Its application 

can therefore be readily understood from Fig. 52, 

and what has been just said. It draws the shoulders 

forwards, and will, of course, unite longitudinal wounds 

over the pectoral 

muscles, or prevent Fig. 53. 

contractions in the 

cicatrices of burns 

on the back. By 

placing compresses 

over the upper part 

of the sternum, it 

may also be usefully 

employed in injuries 

of this part, as well 

as in dislocations 

anteriorly, of the 

sternal end of the 

clavicle. 

THE SPICA OF THE 
SHOULDER, 

Like most of the spi- 
ca bandages, forms 
one of great neat- 
ness, and well cal- 
culated for making pressure on this part. It is formed 
by a roller eight yards long and two and a-half inches 




90 THE CROSSED, OR 

■wide, with cotton or compresses for the axilla of the 
injured side. 

In applying the bandage commence by making 
one or two spiral reversed turns round the upper part 
of the arm of the injured side, passing from without 
inwards, and from before backwards. Then pass 
from behind the arm, up over the lower extremity of 
the same shoulder ; obliquely downwards, over the 
front of the chest to the axilla of the sound side ; 
thence round the back ; obliquely upwards, over the 
shoulder, and down in front under the axilla of the 
injured side, which should be previously furnished 
with the compress or cotton, in order to protect it. 
From this point go behind and over the shoulder, 
to pursue exactly the same course as before, until 
the bandage is nearly exhausted, each turn covering 
in, however, only one-third of the preceding turn. 
Then terminate it by one or two circulars of the 
trunk, or of the arm, and pin it, as in Fig. 53. 

Uses. — This beautiful bandage, named from the 
resemblance in its folds to the arrangement of the 
leaves of an ear of corn, exercises a very exact com- 
pression around the extremity of the shoulder, at a 
point where it would otherwise be difficult to make 
pressure. In cases of dislocation of the humeral ex- 
tremity of the clavicle it will be found of great ser- 
vice in keeping the clavicle reduced, especially if 
the arm be also well supported. But great care is 
requisite to protect the edges of the axilla, other- 
wise they will be injured by the turns of the roller. 

When this bandage is made to mount gradually 
from the point of the shoulder towards the neck it is 
called a Spica Ascendens ; but if its turns come from 
the neck to the shoulder it becomes a Spica Descend- 
ens. Of course, it is optional with the surgeon to 
make either the one or the other, as the result de- 
pends on the point where the first turn, after leaving 
the arm, is made to cross the chest. 



FIGURE OF 8 BANDAGES. 



91 



THE FIGURE OF 8 OF THE NECK AND AXILLA 

Is formed by a roller five yards long and two inches 
wide, the initial extremity of which is placed on the 
side of the neck, and fixed by one or two circular 
turns of the neck, loosely applied; making them, for 
example, from behind forwards, and from left to 
right. Next, di- 
rect the roller as Fi 9- 54. 
it comes from the 
left side of the 
neck, over and be- 
hind the right 
shoulder, so as to 
enable it to con- 
fine any dressings 
that may be re- 
quired either there 
or in the axilla ; 
then come up in 
front ; over the 
shoulder ; round 
the neck to the left 
side ; and cover 
by each turn only 

one-third of the preceding turns, so as to make a 
figure of 8, one turn of which shall embrace the neck 
and the other the axilla. 

Uses. — This bandage will prove useful in retaining 
dressings before, behind, or above the shoulder, or 
in the axilla, or at the base of the neck, as it is easily 
applied, and if not drawn too tight does not restrain 
the motions of the arm. It may also be made with 
a double-headed roller, the body of the bandage being 
applied under the axilla, and the heads crossed upon 
the shoulder of the opposite side, and then brought 
round the neck to cross on the shoulder of the in- 
jured side. It is firmer, as thus applied, than the 




92 



THE CROSSED, OR 



single-headed roller, but is apt to press too much on 
the armpit and interrupt the circulation, or cause 
cramps in the hand, if care is not used in its appli- 
cation. 



THE CROSSED OF ONE BREAST 

Requires a roller eight yards long by two and a-half 
inches wide ; that the patient should be sitting up 
without the back touching a chair, and that the sur- 
geon should stand in front, or on the outside of the 
limbs of the patient, and not in front of her knees 
or behind her back, as the last turns of the bandage 
are apt to render such a position extremely awkward. 
In applying this bandage fix the initial extremity of 
the roller behind the shoulder of the affected side, 
say the right; then carry it obliquely across the back, 
over the opposite shoulder, and descend on the front 
of the chest to pass from before backwards under 
the breast and axilla of the injured side. Fix by 

this turn the initial 
Fi 9- 55 - extremity of the 

roller, and go over 
the same course 
once or twice, so as 
to form two or three 
obliques of the neck 
and axilla. Then, 
on coming to the 
axilla of the diseased 
breast the third time, 
direct the roller 
transversely across 
the back, to the axilla 
of the opposite or left 
side, and return by 
a horizontal turn in 
front of the chest, to 
the point of departure, in order to commence another 




FIGURE OF 8 BANDAGES. 93 

oblique of the neck and axilla. Continue thus making 
obliques of the neck, and horizontal turns of the body, 
each turn ascending and covering in one-third of the 
preceding one till the roller is exhausted, when it 
will be found that the breast is firmly slung, or sup- 
ported by the oblique turns, and compressed by the 
circular (Fig. 55). 

Use. — This bandage is not only useful in retain- 
ing dressings to the breast, but also in supporting 
the breast itself when requisite, as in cancer, lacta- 
tion, &c. It will readily keep its place, unless 
handled, for thirty-six hours. It may, however, if 
it should be requisite to change the dressing twice 
or thrice a-day, be supplanted, in cases of simple 
dressing, by the sling of the breast, as described 
hereafter, and the patient will thus be saved the fatigue 
of a re-application of the bandage. 

THE CROSSED OF BOTH BREASTS, 

Having more surface to travel over, requires a roller 
twelve yards long and two and a-half inches wide, 
rolled either into one or two heads. If the patient 
is very large it may require a roller of fifteen yards. 
In order to apply it, carry the initial extremity of a 
single-headed roller behind the right axilla ; thence 
by crossing the back direct the cylinder over the 
left shoulder ; pass obliquely across the front of the 
chest, under the right breast, and under the right 
axilla to the point of departure. Make thus two or 
three obliques of the neck and axilla, covering in the 
breast by the gradual ascent of each turn, and on 
reaching the back of the right axilla in the third turn, 
pass transversely across the back to the left axilla ; 
under this and across the chest in front of the left 
breast to the right side of the neck; thence across 
the back to the left axilla. Make thus two obliques 
of the neck and this axilla, and on coming to the 
front of this armpit pass transversely under both 



94 



THE CROSSED, OR 



breasts to the right axilla, and under this to the 
point of departure, taking care that each revolution 

Fig. 56. 




covers successively the breasts from below upwards, 
without being drawn too tight. If the course here 
laid down be rigorously followed, we shall have an 
oblique of the neck and each axilla, with horizontal 
turns before and behind, so that each turn of the 
roller will be found to mould itself with great ac- 
curacy to the roundness of the breasts and make 
gentle and equable pressure on them, a point of 
some importance in certain cases of mammary ab- 
scess. 

Use. — This bandage, like the preceding one, is 
employed to support or compress both breasts, and 
is exceedingly useful in patients who are annoyed by 



FIGURE OF 8 BANDAGES. 95 

pendulous mammas during lactation, &c. It may, 
however, be as well applied by using a double-beaded 
roller. In this case, place the body of the bandage 
in front of the sternum, and carry each cylinder 
under its respective axilla to form an oblique of the 
neck and axilla, crossing on the back. After one or 
two obliques, carry one cylinder horizontally in front 
of, the other horizontally behind the chest, to make 
a half transverse turn, and then make other oblique 
and semi-transverse turns of the body till the whole 
is covered. 

THE SPICA OF THE GROIN, OR FIGURE OF 8 OF THE 
PELVIS AND THIGH, 

Requires a single-headed roller eight or ten yards 
long, three inches wide, and compresses. 

Fig. 57. 




Having arranged the dressing, place the initial ex- 
tremity of the bandage above one of the iliac crests, 
and make two horizontal turns around the pelvis, in 
order to fix the point of the bandage, turning from 
right to left, and from before backwards, if for the 



96 THE CROSSED, OR 

right groin, and the reverse if for the left. Arriv- 
ing in front of one of the groins, say the right, de- 
scend to the inside of the thigh, between it and the 
genital organs, and winding round the back part 
ascend on the outside to cross the first turn ; thence 
to the ileum of the opposite side; across the back 
and round the pelvis, to follow the same course until 
the cylinder is nearly exhausted, when the whole 
may be fastened by a circular turn of the pelvis. 

Use. — This is an excellent bandage to retain 
dressings, or make compression on buboes, venereal 
ulcers, abscesses, &c, situated at the groin. If it is 
intended to make a Spica Ascendens, the first turn 
over the groin should go as far down the thigh as 
the point to be covered by the bandage, and each 
turn covering in only one-third of that which pre- 
ceded it should be made to mount gradually upwards. 
If, on the contrary, it is wished to make pressure 
from above downwards, the first turn should cross 
the groin high up, near the abdomen, and each sub- 
sequent turn descend, so as to form a Spica De- 
scendens. 

This bandage by covering the groin is exceedingly 
useful after operations for strangulating hernia, or 
in cases of simple hernia, where compression is re- 
quired and a truss cannot be borne or obtained. 

THE SPICA OF BOTH GROINS 

Is formed by a single-headed roller twelve yards 
long and two and a-half or three inches wide, two 
horizontal turns of which should be made about the 
pelvis, going, for example, from right to left and 
from before backwards. Upon arriving at the second 
turn, near the left groin, the head of the roller should 
be made to pass obliquely downwards along the outer 
side of this thigh, and to ascend along its inside so as 
to cross the first descending turn ; after which it may 
be conducted round the back of the pelvis as far as 



FIGURE OF 8 BANDAGES. 97 

the right groin, and passing hence along the inner 
side of this thigh, remount on its outer side, and then 
pass again round the pelvis in front, and to the left ; 

Fig. 58. 




the head of the roller being made to pursue the 
course just indicated, until only a sufficient quantity 
remains to terminate the bandage by two horizontal 
turns of the pelvis. 

Use. — Same as the former, but for both groins. 

The Spica of both groins may be very advanta- 
geously made with a double-headed roller, if the body 
of the bandage be applied to the front of the abdomen, 
in a line with the crests of the ilia, and each head 
be carried so as to cross behind the back and come 
round on the groins. Then let each head descend 
in the line of the groin ; between the genitals ; on the 
inside of each thigh, and pass under, behind, and on 
the outside, to run, one to the right the other to the 
9 



98 



THE CROSSED, OR 



left iliac crest, and thence round the back, following 
the same course. 

No bandages can be firmer or simpler than these 
Spica bandages, when it is requisite to make firm 
compression on each groin ; but otherwise, as in cases 
requiring poultices, they will prove inconvenient, from 
the difficulty consequent on moving the patient in their 
re-application. For a more simple bandage for this 
purpose, see the triangular T of the groin. 

THE FIGURE OF 8 OF THE ELBOW 

Is made of a roller two yards long and two or two 
and a-half inches wide, by placing the initial extre- 
mity on the external and 
Fi 9- 59. upper part of the fore- 

arm, and then passing 
obliquely over the bend 
of the arm to the in- 
ternal tuberosity of the 
humerus ; round, above 
the olecranon to the 
external tuberosity ; 
thence obliquely across 
the front, crossing the 
first turn like an X, to 
the inner and upper 
part of the forearm, and 
then across the back to 
the point of departure, to run the same course. If 
the arm is much flexed, make one circular over the 
point of the elbow, after the formation of the second 
figure of 8. 

Use, — This little bandage, when the arm is either 
flexed or extended, is very useful in covering in the 
elbow-joint, and is, therefore, added to the Spiral of 
the Upper Extremity for this purpose. It is also 
requently employed to retain the compress used 
after bleeding, as seen in Fig. 59. 




FIGURE OF 8 BANDAGES. 



99 



THE FIGURE OF 8 OF THE WRIST 

Is made like the preceding, by taking one or two cir- 
cular turns around the wrist, either on its dorsal or 
palmar face, then on reaching the cubital side run 
obliquely across to the space between the thumb and 
fore-finger, say of the right hand ; then obliquely over 
the palm to a corresponding point on the metacarpal 
bone of the little finger ; hence obliquely across the 
back of the hand to the wrist-joint; thence make a 
semi-horizontal turn around the wrist to the ulnar 
side, and run the same course over again, as seen in 
the Spiral of the Upper Extremity. 

Use. — To cover in and compress the wrist-joint. 
It is also added to the Spiral of the Upper Extre- 
mity, in order to cover in this joint. 

THE SPICA OF THE THUMB 

Is made by a roller three yards long and a finger's 
breadth wide, of which the initial end is fixed upon 
the wrist by two or three circular turns. After the 
last turn, which should terminate upon the radial side, 
direct the head of 

the roller from the Fi 9> 60. 

external to the in- 
ternal side of the 
thumb; pass be- 
tween the thumb 
and the index fin- 
ger ; return and 
cross the base of 
the thumb, and 
carry it onward 

again about the wrist. Repeat these double obliques 
and cover in about two-thirds of each turn by teh 
subsequent one, so as to form a spica (Fig. 60). 

Use. — This bandage will be found very useful in 
retaining dislocations of the first metacarpal bone of 
the thumb, or for making pressure on this part. 




100 THE CROSSED, OR 



THE FIGURE OF 8 OF BOTH THIGHS 

Requires a few turns of a roller two and a-half inches 
wide, in the ordinary figure of 8. 

Use. — To keep the thighs together, as after the 
operation of lithotomy, or after the reduction of a 
dislocation of the femur. 

THE FIGURE OF 8 OF THE KNEE 

Requires a roller two and a-half inches wide, of which 
the initial extremity is to be fastened by one or two 
circular turns below the knee. Then pass obliquely 
over the patella, say from the outside to its inside ; 
make a semi-horizontal turn on the back of the thigh, 
above the joint, to reach the external condyle; go 
thence obliquely over the patella to the inner side of 
the tibia ; pass round behind it to the head of the 
fibula, and run the same course again till all is 
covered, as seen in the Spiral of the Lower Extre- 
mity. 

Use. — To cover in the knee, or compress the joint. 
It is also added to the Spiral of the Lower Extre- 
mity, in order to cover in this joint, especially in 
fracture of the patella. If it is wished to retain a 
dressing to the popliteal space, we have only to re- 
verse the turns of the bandage ; that is, start it by 
circular turns from within, outwards, and cross from 
below the knee behind, to above it in front. 

THE FIGURE OF 8 OF THE ANKLE AND INSTEP 

Is made by a roller two and a-half inches wide, and 
of the ordinary length. 

If in the right foot, place the initial extremity 
above the external malleolus, and make two circular 
turns to fix it ; then on coming to the external mal- 
leolus on the second turn, pass obliquely over the 
front of the instep to the tarso-metatarsal articula- 
tion of the big toe; thence under the sole of the 




FIGURE OF 8 BANDAGES. 101 

foot to its outside ; horizontally over the instep to 

the same point, and then pass 

obliquely over to the external Fi 9- 61 - 

side of the os calcis; over this 

side of the bone, and round its 

point, up on its inside to cross 

the anterior extremity of the 

astragalus ; over the upper part 

of the instep ; down the outside 

at the point of the cuboid bone ; 

under the sole to the inside of the 

calcis; around its point to the 

outside, and up over the instep to the point where the 

cuneiforme internum is placed, and thence follow a 

similar course till the heel is covered in, which is 

generally done in two turns and a-half of figures of 

8. To cover in the extreme point of the heel be 

careful that each turn that goes over the sole, is kept 

as much backwards towards the point of the heel as 

possible. The bandage will not slip off, if drawn 

moderately tight. The turns may be made as in Fig. 

61, or in Fig. 46. 

Use. — This bandage may be resorted to where we 
wish to retain dressings to the heel, instep, or front 
of the ankle-joint, as in excoriations from the extend- 
ing band of the apparatus for fracture of the thigh. 
It is also added to the Spiral of the Lower Extremity, 
when we wish to cover in the heel as well as the whole 
limb, as in the Compressing Bandage. 

RIBBAIL'S BANDAGE, OR THE SPICA OF THE INSTEP 

Is a neat bandage, made of a single headed roller 
seven yards long and two inches wide, by laying the 
initial extremity of the roller on the tarsal end of the 
metatarsal bone of the little toe, if in the right foot, 
or on that of the big toe, if in the left. Then pass- 
ing obliquely over the front of the foot to the first 
joint of the big toe in the right foot, or that of the 
9* 



102 THE CROSSED, OR 

little toe if in the left, go under the sole of the foot 
horizontally, in a line with the metatarso-phalangeal 
articulation, to the outer or inner side of the foot, 
according to circumstances. From this point make 
two oblique turns over the front of the foot, which 
will bring us to the instep on its inner or outer side, 
and then pass directly to the point of the heel in a 
line parallel with the sole of the foot, the edge of the 
roller projecting a little beneath the sole; thence 
around the heel to come to the instep again, keeping 
still parallel with the sole of the foot ; cross the in- 

Fig. 62. 




step and make another turn similar to the first, which 
shall embrace the heel and instep, cover in one-third 
of the preceding turn, and form a spica on the instep 
(Fig. 62). Continue these turns, gradually ascend- 
ing, till the foot will hold no more, when we may ter- 
minate the bandage by circular turns above the ankle, 
or else form a spiral up the limb. 

Use. — This forms a most excellent and neat band- 
age for cases requiring firm compression of the instep 
or ankle, as in wounds of the anterior or posterior 
tibial arteries at these points. The figure shows the 
best position of the limb of the patient and of the 
surgeon. For it, as well as for many other practical 
details, I am indebted to M. Bibbail, of Paris, from 



FIGURE OF 8 BANDAGES. 103 

whose excellent course on Minor Surgery much that 
is of daily service has been gained. 

The Figure of 8 of the Toes, or the Spica of the 
Big Toe, is so precisely similar to such bandages in 
the fingers and thumb, as not to require a repetition. 
In applying any of them make a few circulars of the 
instep instead of the wrist, and then proceed exactly 
as in the hand. 



CHAPTER IV. 

OF THE KNOTTED BANDAGES. 

These bandages, named from their making a knot 
like that known as the Packer's Knot, are formed by 
double-headed rollers, and intended to make firm 
compression on particular points, as on bleeding ves- 
sels, &c. The only one of importance is that for 
the head, which is used to arrest hemorrhage from 
the temporal artery. Under this class we may, how- 
ever, with great propriety include all those which 
are terminated by bow-knots, as the 8 of the elbow 
after bleeding at the bend of the arm; that of the 
ankle, as well as the Sailor's Knot, Clovehitch, and 
others employed in the treatment of Dislocations. 



THE KNOTTED BANDAGE OF THE HEAD 

Is made of a band five yards long and two inches 

wide, rolled up into two 
heads of unequal size, one 
being a fourth larger than 
the other. In applying 
it, place the body of the 
bandage over the gradu- 
ated compress covering 
the wounded artery, and 
conduct the two heads one 
before, and the other be- 
hind, to the opposite tem- 
ple, where they should be 
reversed, in order to re- 
turn to the point of depar- 
Now give them a turn or twist, so as to enable 




ture. 



THE KNOTTED BANDAGES. 105 

one to pass over the summit of the head, and the other 
underneath the chin, to the sound side. When they 
meet, reverse them as in the first instance, and from 
thence conduct them in the same course to the point 
of departure on the wounded vessel. A second twist 
being effected, let them pass for the third time to the 
opposite temple, then for the third time return hori- 
zontally, and knotting them firmly, let each knot be 
placed behind the one first formed ; the bandage being 
then conducted, one head over the vertex and the 
other underneath the chin, is terminated by a few 
circular turns of the forehead and occiput. 

Use. — For arresting hemorrhage of the temporal 
artery, or any of its branches. It is, however, a 
painful bandage, in consequence of the compression 
made on the lower jaw, or on the point of injury. It 
therefore requires constant attention, lest it remain 
on too long, or be too tight. It is usual to close 
the opening in the vessel first with a piece of adhe- 
sive plaster, as will be seen hereafter when treating 
of Arteriotomy. 



CHAPTER V. 

OF THE RECURRENT BANDAGES. 

The Recurrent Bandages are formed by convolu- 
tions or parabolic and recurrent turns, which make 
a kind of cap for the parts to which they are applied. 
Unlike most caps, however, they are exceedingly apt 
to become relaxed. Although very neat in their 
appearance, these bandages require more watching 
than is convenient, consequently they are often sup- 
planted by other dressings. When required, they 
may be made either with the single or double-headed 
roller ; but from the difficulty of removing the latter 
without its coming off in mass, and thus perhaps 
bringing ligatures, &c, altogether, those formed by 
the single-headed roller are most generally em- 
ployed. 

THE RECURRENT OF THE HEAD 

Is composed of a single-headed roller five yards 
long and two inches wide, the initial extremity of 
which is placed on one side of the head on a line with 
the supra-orbitary ridge, whilst the cylinder is car- 
ried two or three times round the head by circular 
turns. On coming to the middle of the forehead in 
the second turn, the bandage should be reversed and 
the reverse confined with one hand, while the cylinder 
is carried over the top of the head in the line of the 
sagittal suture, to the occipital protuberance, reversed 
here, and there held by an assistant. Then coming 
obliquely over the head to the forehead, make an- 
other reverse to go to the occiput, each turn cover- 
ing in one-third of the preceding one, and continue 



THE RECURRENT BANDAGES. 



107 



thus, till the horizontal turn on the right or left side 
of the head is reached. Cover the opposite side by- 
similar turns, seeing that each reverse conies to the 
same point, in front and behind, and terminate the 

Fig. 64. 




bandage by circular turns, firmly applied around the 
reversed turns, as in Fig. 64. 

Use. — To retain dressings to the head, as in the 
application of blisters to the scalp — in erysipelas, in 
wounds, and in other injuries of the scalp, &c. But 
care must be taken not to draw the horizontal turns 
too tight, lest, as in the case related by Percy, ulcera- 
tion or gangrene of the scalp ensue. 

THE RECURRENT OF THE HEAD, 

As made by a double-headed roller, requires that the 
body of the bandage be placed upon the occiput or 
forehead, so that after two or three circular turns 
the rollers may be made to intersect each other upon 



108 



THE RECURRENT BANDAGES. 



Pig. 65. 



the occiput. One of them is then to be reflected over 
the vertex to the forehead, 
while the other continues in 
a circular course on the side 
of the head. Then crossing 
each other upon the forehead, 
the first head is carried 
obliquely backwards to the 
occiput, and reflected by the 
side of the other, while the 
last, a, is continued in a cir- 
cular direction. The first, 
b, being again brought over 
the head, from behind for- 
wards, is to be carried in 
this way backwards and for- 
wards, in reverses, till the head is entirely covered. 

Use. — This, like the previous bandage, serves to 
confine dressings upon the head, but is now rarely 
employed for the reasons stated. The ancients, by 
its means, exerted compression on the heads of 
Hydrocephalic patients. 




THE RECURRENT OF AMPUTATIONS 

Embraces two varieties, according as it is made with 
a single or double-headed roller. As, however, it is 
difficult to remove the latter, I shall only give the 
application of the former, which is made of a single- 
headed roller, of different lengths according to the 
volume of the stump to be covered, but generally two 
or two and a-half inches wide. 

The position of the patient for the application of 
this bandage should be such as is most easy to him, 
the stump being well supported and the integuments 
pushed over the end of the bone by assistants. 

Then having arranged the Malteese Cross, and 
other dressings, place the initial end on the surface 
of the limb, three or four inches above the extremity 



THE RECURRENT BANDAGES. 



109 



of the stump ; make two or three circular turns to 
fix it, and on coming to the central point of the under 
portion of the limb, reverse the roller, so as to run 
up in front of the stump and over its upper surface 
to a point, A (Fig. 66), four or more inches above 
its extremity. Fix all these reverses by the fingers 

Fig. 66. 




of one hand, if the size of the limb will permit; if 
not employ an assistant for the reverses on one side, 
and continue to make them till the whole face of the 
stump is covered, when the bandage is to be termi- 
nated by spiral reversed turns, which, starting from 
the circumference of the stump, B, run up a few 
inches above the first turn of the bandage, and are 
there confined by a pin. If there is a tendency to 
spasm of the stump, the ends may be carried on and 
fixed fast to the pillow or bed on which the limb lies. 
But care is requisite not to draw the recurrent turns 
at A too tight, lest by compressing the soft parts 
10 



110 



THE RECURRENT BANDAGES. 



against the point of the bone they cause irritation 
and spasm, and create the jerking that is so great 
an annoyance. 

The figure also shows the application of a Sus- 
pensory Bandage to the Testicles. 



CHAPTER VI. 

OF THE COMPOSITION AND APPLICATION OF THE COM- 
POUND BANDAGE, OR THE BANDAGE PROPER. 

It has been already stated, that usage having justi- 
fied the application of the term Bandage to what 
should be strictly known only as the Roller, I should 
describe the Bandage Proper under the head of Com- 
pound Bandages. 

These include a considerable number of the most 
useful means of retaining dressings ; and as their ap- 
plication is generally simple, though their composi- 
tion is sometimes a little complicated, I shall pay 
the most attention to the latter, believing that 
after they are constructed their application will be 
simple. 



THE SINGLE T, OR CRUCIAL BANDAGE, 

Named from its shape, is composed of a horizontal 
portion, sufficiently 
long to go entirely Fi 9- 6 ?. 

round the part to be 
covered, and yet leave 
enough to make a bow- 
knot, and of a vertical 
piece, which is half the 
length of the horizontal 
one, and generally at- 
tached firmly to its 
middle, so as to form 
the perpendicular por- 
tion of the T (Fig. 67). Each portion should be rolled 






112 



into a 



COMPOUND BANDAGE, OR 



Fig. 68. 




cylinder, and confined by a pin previous to its 
application, in order to ensure 
its smoothness when applied. 

The vertical portion varies 
considerably in its shape and 
length. Sometimes there are 
two vertical pieces, as in the 
Double T ; and sometimes it is 
three or four inches wide, and 
slit into two tails to within a 
short distance of the horizontal 
band, as in Fig. 68. In others 
a triangular piece is added, &c, 
&c, as will be seen hereafter 
in the special applications of 
this bandage. 



THE T BANDAGE OF THE HEAD 

Requires a horizontal piece of bandage two yards 

long and two inches wide, upon which, at about one- 
third of its entire length, a 
strip half a yard long and of 
the same width, is stitched at 
right angles, to form the ver- 
tical portion. The bandage 
then being rolled into two 
heads, the surgeon places 
himself before the patient 
and applies the body of the 
bandage to the middle of the 
forehead, with the edge, cor- 
responding to the vertical 
portion of the bandage, up- 
permost, in' order that the 
latter, after traversing the 

vertex, may hang loosely down the nape of the neck. 

Then passing the remainder of the horizontal portion 



Fig. 69. 




along the temples to the occipital region, he crosses 



BANDAGE PROPER. 113 

the vertical strip, which should be immediately re- 
flected upwards, and secured upon the brow by the 
last turns of the horizontal portion. A double T 
may be formed by stitching a second strip upon the 
transverse portion of this, at a convenient distance 
from the first. 

Use. — This light bandage may be used for retain- 
ing dressings to the scalp when the vertical band is 
so placed that it may run over the point to be covered. 
Where the dressing is small it is preferable to the 
recurrent bandage of the head, as it is not so heating. 

THE T BANDAGE OF THE EAR 

Is made of a horizontal portion two yards long, of a 
vertical one a half yard in length, and of a piece of 
linen of the shape and size of the external ear. Sew 
the horizontal band to 
the summit of the ear- Fig. 70. 

shaped piece of muslin, 
and attach the vertical 
one to the opposite 
portion or that corre- 
sponding with the soft 
part of the ear. Then 
place the circular band 
around the head above 
the ear of the affected 
side, and the muslin 
over or close behind 
the ear, and carry the vertical band under the jaw 
and up on the opposite side, where it will be con- 
fined by the horizontal turns. 

Use. — This modification of the T is an excellent 
bandage for retaining dressings to or behind the ear, 
especially the latter. Every one has felt the difficulty 
of retaining blisters or dressings to this part ; but the 
construction of this little bandage removes it entirely. 
If made of black silk and narrow ribbons, it would 
10* 




114 



T BANDAGES. 



hardly be noticed in persons wearing whiskers, or in 
those wearing caps or bonnets. 

THE DOUBLE T OF THE NOSE 

Is made of a band one inch wide and two yards long 
and of two other bands of the same width, but one yard 
long, the latter being sewed on the former, so that 
they may be one inch apart, and at right angles to 
the first band. After this the transverse band should 
be placed upon the upper lip, with the border to 
which the vertical bands are attached turned up- 
wards ; and the two extremities being carried over 
each cheek, and under the ears to the nape of the 
neck, be there held by an assistant. Then cross the 
vertical bands upon the root of the nose, and carry 
each one over the parietal 
Fig. 71. protuberance of its side, and 

down to near each mastoid 
process, under the horizon- 
tal band. Turn them over 
this to come upwards, and 
fix them by bringing the re- 
mains of the horizontal band 
from its crossing on the nape 
of the neck round the fore- 
head; where they may be 
fastened either by a knot 
or a pin (Fig. 71). 

Uses. — This little band- 
age is very useful in retain- 
ing dressings to the upper 
lip and root of the nose, especially in cases of frac- 
ture of the bones of the latter, or in epiphora, or 
fistula-lachrymalis, as it is easily renewed, and does 
not interfere with the use of the eyes, nose, or mouth ; 
whilst it acts on the part nearly as firmly as adhesive 
plaster, without being liable to its objection. 

The single T bandage of the nose is also a useful 




T BANDAGES. 



115 



mode of retaining dressings to its surface ; but as it 
is much improved by the addition of a suspensory, it 
will be treated of under the latter bandages. 

THE DOUBLE T OF THE CHEST 

May be formed of a broad piece of muslin, and of a 
band two feet long split nearly to the end ; or of two 
distinct bands of the same length, which are to be 
attached to its upper edge. Then pass the muslin 
around the chest, and 
bringing the two 
extremities forwards 
stitch them to the first 
piece. Or the bands 
themselves may be 
brought forward over 
each shoulder and se- 
cured in front, so as to 
form shoulder-straps. 
(Pig. 72.) 

Use. — In cases of 
fractures, to compress 
the ribs, or to retain 
dressings to the back. Frequently buckles and 
straps are fastened to the ends in front, and buttons 
to the upper edge to receive the shoulder-straps ; 
these make the bandage much firmer, but also a little 
more complicated in its composition. 

THE DOUBLE T OF THE ABDOMEN 

Consists of a piece of muslin, to one of the borders 
of which are stitched, at equal distances from its 
centre, two narrow bands half a yard long, to serve 
for thigh or perineal straps. They should be at- 
tached sufficiently apart to correspond with the great 
trochanters. 

In its application, the middle of the muslin should 
be placed around the pelvis, and the extremities 




116 



T BANDAGES. 






brought round on the abdomen, where they overlap 
and pin. The vertical bands should then be con- 
ducted from behind forwards ; crossed under the 
perineum, and fixed upon the forepart of the hori- 
zontal band. 

Use. — To retain poultices or other dressings to 
the abdomen ; to exert compression on this part 
after the operation of paracentesis, or after deliv- 
ery, although its application then belongs rather to 
the accoucheur than to the surgeon. 

This is the reverse of the T of the chest, the ver- 
tical bands being made to pass under the pelvis in- 
stead of over the shoulder. 

THE TRIANGULAR, OR COMPOUND T OF THE GROIN, 

Requires a piece of muslin four inches wide at its 
base and ten inches long, made of a triangular shape, 

in order to correspond 
Fig 73. with the upper and in- 

ternal part of the thigh. 
To the base of this sew 
a horizontal band about 
a yard and a-half in 
length ; and to its sum- 
mit a vertical one three- 
quarters of a yard long. 
The dressings being 
then placed on the part, 
the extremities of the 
horizontal band are car- 
ried round the pelvis on 
either side as far as the 
sacrum, whence they are returned and tied in a bow 
above the pubes, whilst the vertical band and the 
triangular piece passing down between the thigh and 
scrotum, the former comes up over the outside of the 
thigh, and is attached to the transverse portion of 
the bandage. 




T BANDAGES. 



117 



Use. — To retain dressings upon the groin of a 
patient confined to bed, as in poulticing buboes, or 
after operating for hernia. This bandage will be 
found to be one of the best bandages that we can 
employ for retaining dressings to the groins in cases 
where it is requisite to renew them frequently, and 
especially when it is difficult to move or raise the 
patient ; it being only necessary to untie the verti- 
cal band and draw it from under the thigh, in order 
to lay open the whole groin to our view, which may 
be readily done without the least movement on his 
part. 



THE DOUBLE T BANDAGE OF THE BUTTOCK 



Fig. 74. 



Requires a roller two yards long and three inches 
wide, and also two vertical 
bands each half a yard in 
length and two inches broad 
stitched to it at right angles, 
at about one-fourth of its 
length. Then the horizon- 
tal band being placed around 
the pelvis, so that the verti- 
cal bands may correspond to 
the median line of its pos- 
terior face, its extremities 
are fixed with pins, and the 
vertical bands brought under the perineum and fas- 
tened to its front portion. 

Use. — This is the common double T bandage em- 
ployed to retain dressings to the perineum, anus, or 
vagina, in cases of piles, prolapsus ani, and fistulae. 
Instead of the two tails, that formed by slitting the 
single T may be used, as seen in Fig. 68. 




THE T BANDAGE OF THE HAND 

Is composed of a narrow bandage or piece of tape 
one inch wide and half a yard long; and of a second 



118 



T BANDAGES. 



piece one yard long. Sew the longest piece to the 
other, in order to form the vertical portion of a T, 
and place the horizontal band on the back or front 
of the wrist, so that the vertical band may present 
to the fingers. Carry the latter portion over the 
back or front of the hand, over the interdigital 
space of the first and second finger ; come up again 
to the wrist, and surround it by a half turn of the 
horizontal piece ; reverse the first over the latter to 
return to the space between the middle and third 
finger, retaining the dressing, and coming up to the 
wrist again ; surround it again by the horizontal 
band ; reverse the vertical one in order to pass be- 
tween the ring and little finger, and on the outside 
of the latter to the wrist, where it may be fastened 
by the turn round the joint. 

Use. — This is a very light bandage for retaining 
dressings to the interdigital spaces, as well as the 
body of the hand, and offers a substitute for the 
gauntlet or demi-gauntlet, before seen. 

THE PERFORATED T OF THE HAND 

Is made of a two inch roller one yard long, and of a 

piece of muslin of the 
Fig. 75. breadth, and twice the 

length, of the palm of 
the hand. Fold the 
muslin on itself in its 
length, and cut in it 
four circular openings, 
as at D, about three 
lines apart, to corres- 
pond with the fingers. 
Then sew one of its ex- 
tremities at right angles 

to the roller or horizontal band, as in Fig. 75. 
Pass the fingers through the openings, and stretch 

the muslin over the back and front of the hand, con- 




T BANDAGES. 119 

fining the loose end by a few circular turns of the 
roller around and above the wrist. 
Use. — Same as the above. 

The T bandages of the Feet being similar in their 
formation and application to the above, do not require 
a special description. 



CHAPTER VII. 

OF THE INVAGINATED, OR SLIT AND TAIL 
BANDAGES. 

Of the Invaginated Bandages there are two kinds, 
one, in which the same roller is formed at one end 
into strips or tails, and at another part into slits or 
button-holes ; the other, in which two distinct bands 
are thus prepared. In either case, the tails of one 
part are passed through the openings in the other, 
and by acting on compresses, approximate all the 
portions under them. The first is employed to assist 
the union of longitudinal, the second is used to ap- 
proximate transverse wounds, as well as in the treat- 
ment of certain fractures. When wounds are deeply 
seated, the application of adhesive strips only causes 
apposition of the surface and leaves the parts below 
separated, so that as the secretion of pus continues 
a bag or cyst is formed, from which the matter can- 
not escape except by burrowing beneath the tissue. 
When, also, divided parts have a tendency to con- 
tract, they very frequently tear out the stitches, and 
it is in both these cases that these bandages will be 
found exceedingly useful. 

THE INVAGINATED BANDAGE, FOR VERTICAL WOUNDS OF 
THE LIP, 

Is composed of a roller two or three yards long and 
one inch wide, rolled into two heads, and of two 
small compresses about two inches square, which 
are to be placed on the cheeks, near the angle of 
the mouth. 

In applying this bandage place the body of the 



THE INVAGINATED BANDAGE OF THE BODY. 121 




roller on the forehead, or on the nape of the neck 
near the occiput, and 
carry each cylinder Fi 9- 76 - 

round under the lower 
part of the ear, over the 
malar bones, and over 
the compresses to the 
lip. Then slit in one 
bandage a hole large 
enough to admit the 
other roller ; pass 
this through and draw 
upon each ; carry them 
both round to the nu- 
cha, and then run the 
same course till the parts are well supported and 
covered in, as in Fig. 76, terminating on the fore- 
head. 

Use. — In vertical wounds of the lip where other 
means are not at hand, or to support the hare-lip 
suture and prevent its cutting out. By the pressure 
which it makes on the lip, it is also useful in arrest- 
ing hemorrhage from the coronary arteries. 

THE INVAGINATED OF THE BODY 

Is composed of a double-headed roller of a length 
sufficient to go several times round the body, and of 
two compresses of the length of the wound. The 
body of the bandage being placed on the back, and 
the heads brought round under each axilla, and over 
the compresses on each side of the wound, make a 
slit in the roller of one side, and pass the cylinder 
of the other side through it, by which means the 
wound will be well closed. Continue to do this as 
often as may be necessary. 

Use. — To unite longitudinal wounds of the chest 
or abdomen, or to support the parts after the re- 
moval of the breast. 
11 



122 



INVAGINATED ? OR 



Fig. 77. 



hrihT 



THE INVAGINATED BANDAGE FOR LONGITUDINAL WOUNDS 
OF THE EXTREMITIES 

Is made of a piece of linen, sufficiently long to 
make three or four turns of the part to be treated, 
and of a breadth corresponding to the length 
of the wound. Divide this piece so as to 
form three tails, long enough to embrace 
three-fourths of the part wounded. At a 
convenient distance further on, make three 
longitudinal perforations, opposite to and 
of the same breadth as the tails. Then 
roll up the remainder of the band, and 
make two graduated compresses, of such a 
size as may be required by the wound. 

If the bandage is to be applied to the 
upper portion of a limb, its lower part 
should be first covered by the turns of a 
spiral bandage, after which the undivided portion, 
or that situated between the tails and the slits, being 

applied upon the 
part which is ex- 
actly opposite the 
wound, and the 
graduated com- 
presses placed on 
each side of the 
latter, at the dis- 
of about three 
or four fingers' 
breadth from its edges, the tails are to be passed 
through the corresponding slits, and the edges of 
the wound united by drawing the extremities of the 
bandage in contrary directions; then secure the 
tails by turns of the remainder of the roller, or by 
those of a Spiral one. 

Use. — This bandage may be used in deep-seated 
wounds of the extremities as an adjuvant to adhe- 




UNITING BANDAGES, 



123 



sive strips, as it unites the deep-seated parts as well 
as the skin, thus preventing any distension of the 
inside of the wound, or the formation of an abscess. 

THE UNITING BANDAGE FOR TRANSVERSE WOUNDS 

Will be referred to under the head of Fractures of 
the Patella. 

THE BANDAGE OF WINSLOW FOR WRY-NECK, 

Requires a roller five yards long and two inches 

Fig. 79. 




wide, and some cotton or pads to protect the posterior 
fold of the axilla from the last turns of the bandage. 
The initial extremity of the bandage being then 
placed just above the mastoid process of the affected 
side, carry it thence in front of the parietal protu- 



124 UNITING BANDAGES. 

berance of the same side, over the top of the fore- 
head, and then around the head by several circular 
turns, so as to fix the initial end firmly. Now placing 
a pin or two in the turns on the forehead, as shown 
in Fig. 79, pass down behind the axilla of the sound 
side, over the cotton or compresses previously placed 
there, round under the axilla to the front of the 
chest, and see that it is fastened very firmly to the 
clothing of the patient, or to a band placed around 
the chest, the head being drawn well over to this 
side, before the bandage is completed. The turns of 
the bandage on the head, and the obliquity of its 
course, from the forehead, behind the shoulder, 
round to the front of the chest, fulfil the indications 
of the treatment, by overcoming the inclination to 
the opposite side and turning the head to the front, 
thus opposing the action of the sterno-cleido-mastoid 
muscle of the sound side. 

This bandage affords, however, very slight means 
of acting upon the head, and is apt to slip or stretch. 
Mechanical contrivances have, therefore, very nearly 
displaced it, though it is occasionally employed as 
a temporary dressing. 

APPARATUS OF PROF. JORG, OF LEIPSIC, FOR WRY-NECK. 

" This consists of a pair of leather stays and of a 
band or fillet which goes round the head. On the 
centre of the forepart of the stays is a kind of pulley 
or grooved wheel, which can be turned round with a 
key in one direction but not in the other, as it be- 
comes fixed by means of a spring. From this pulley 
or wheel proceeds a band up the neck to the fillet 
on the patient's head, to which it is fastened directly 
behind the ear, close to the mastoid process. The 
band lies in the same direction as the lengthened 
sterno-cleido-mastoideus muscle, and when drawn 
towards the breast by means of the wheel, produces 
the same effect as would arise from an increase in 
the action of that muscle. In short, it pulls the 



UNITING BANDAGES. 



125 



mastoid process downwards and forwards towards 
the sternum, counteracts the opposite muscle of the 

Fig. 80. 




same name, and rectifies the position of the head. 
Professor Jorg makes his patient wear this apparatus 
day and night, nor does he take it off even when the 
contracted rigid muscles are rubbed with the lini- 
ment that he recommends." 1 



THE UNITING BANDAGE FOR TRANSVERSE WOUNDS OF 
THE NECK 

Is very useful in cases of maniacs, or those bent on 

1 Samuel Cooper's First Lines — by Stevens of New York. 
11* 



126 UNITING BANDAGES. 

suicide by cutting their throats. It requires a single- 

Fig. 81. 




headed roller four yards long ; a piece of bandage 
half a yard long and three inches wide ; a bandage 
for the chest with perineal bands ; and a night cap 
to cover the head. 

Fasten the cap on the patient's head by a few turns 
of the roller, and fasten, at the same time, the band 
by its centre upon the top of the head. The band- 
age being then applied round the chest and pinned, 
secure the band by a few more circular turns of the 
roller, after which its extremities are to be firmly 
fastened to the forepart of the body, the head being 
forced down on the chest so as to bring the chin near 
the top of the sternum. 



CHAPTER VIII. 



OF SLINGS. 





Slings are light bandages of great simplicity, and 
very useful in retaining simple dressings, in conse- 
quence of their not oppressing the part to which they 
are applied. They are formed of pieces of muslin 
of various lengths and widths, split at each extremity 
into two or three tails to within a few fingers' breadth 
of the centre, as seen in Fig. 82. Slings are also oc- 
casionally formed 

of a piece of mus- Fi 9 82 - 

lin of a size suffi- 
cient to cover the 
part to which the 
dressing is to be ap- 
plied, to each end 
of which bands 
are attached to 

serve as tails ; thus making it resemble the an- 
cient slings employed for hurling stones, whence 
their name. In using the sling, the body or 
central part is first applied to the part, and then 
the tails are carried round and confined by knots, or 
pins. 

THE SLING OF SIX TAILS, OR THE BANDAGE OF GALEN, 

Is made of a piece of muslin a yard long and a 
quarter of a yard wide, split at each end into three 
tails to within three finger's breadth of the centre, 
the central tail being somewhat broader than the 
others. The body of the sling being then placed on 
the top of the head, the central tails are passed 



128 



SLINGS. 



Fig. 83. 



along the ears and secured underneath the chin, 
the tails being smoothly folded, 
so as to adapt them better 
to the lower jaw. The frontal 
tails are then directed from 
the anterior to the posterior 
part of the head, where they 
overlap each other, while the 
occipital tails are brought for- 
ward and secured by pins, as 
in Fig. 83. 

Use. — To retain large dress- 
ings, as poultices, &c, to the 
whole scalp. 




THE SLING, OR FOUR-TAILED BANDAGE OF THE HEAD, 

Requires a strip of muslin a yard long and six inches 

broad, split at each end 



Fig. 84. 




fingers 's 



to within three 
breadth of the centre. 
When the wound is on the 
forehead, the body of the 
sling is applied there, and 
the two upper tails carried 
posteriorly and fixed at 
/ "** ' ^ ] (^^^W the back of tne head, 
^•^ whilst the lower tails are 

fastened either upon the 

vertex or beneath the 

chin, as the surgeon may 

consider most convenient. 

In order to confine a 

dressing upon the summit 

of the head, the posterior 

tails should be brought down and secured beneath 

the chin, and the anterior tails, after being carried to 



SLINGS. 



129 



the nape of the neck and crossed, should be fixed be- 
fore the throat, or brought again on the forehead 
(Fig. 84.) 

In applying a sling to the nape of the neck, the 
upper tails are to be 



Fig. 85. 




are 
conducted over the 
forehead, from whence, 
after being made to 
cross each other, they 
are returned, and fas- 
tened at the occiput; 
the lower tails passing 
round the front of the 
neck. This forms the 
sling of the neck, as seen 
in Fig. 85. 

Uses. — These band- 
ages are very simple 
and convenient, and of 
great utility in wounds 

of the head or neck, as they can be applied over 
every point of this portion, by merely changing the 
direction. On the neck, 
especially, the sling Fi 9- 86 - 

forms an excellent band- 
age for retaining blis- 
ters, setons, &c. 

THE SLING OF THE CHIN 

Requires apiece of mus- 
lin six inches by four, 
slit at each extremity 
for two inches, to each 
of which is to be at- 
tached a piece of tape 
or bandage one yard 
long. Then placing the 
body of the sling under the jaw, so that the chin may 




130 



SLINGS. 



be exactly in its centre, carry the two posterior tails 
up over the cheeks and vertex to the mastoid pro- 
cess of each side, where an assistant holds them. 
Then turn the anterior part of the sling and the ante- 
rior tails upwards in front of the chin, and carry the 
front tails under each ear to the nape of the neck ; 
cross them on the neck to come forwards to the fore- 
head, where they may be knotted, after the tails from 
the mastoids have been carried under their posterior 
portion. 

Uses. — In fracture of the jaw without displace- 
ment, and to retain dressings to the front of the chin, 
or under the jaw. 



THE SLING OF THE FACE, OR MASK, 

Is made of a body piece to fit the face, and of four 
tails to hold it in its position. 

In forming the central portion, fold a piece of mus- 
lin, nine or ten inches square, on itself, so as to form 

an oblong square. 
Place this on the 
face so that the 
double side may 
correspond exactly 
with the central 
line of the face, and 
mark on it a line, 
A B, and a circular 
opening, C, for the 
eyes. Make also a 
semicircular, F, for 
the mouth, and a 
small transverse cut, E, to correspond with the end 
of the nose. Then cut off the angles, A H, and I K, 
so as to give it an oval form, and cut out at Gr, two 
triangular pieces, the edges of which are to be sewed 
together to adapt it to the projection of the cheek 
bones. Attach two vertical tails at Gr, and two hori- 




SLINGS. 



131 



zontal ones at A; then open it out and make a ver- 
tical cut, D, from the transverse line at the point of 
the nose, up to the point between the two eyes, as 
in Fig. 87. Apply this to the face and carry the 
upper tails to the occiput; cross them; come round 
on the forehead, and carry the horizontal tails to 
the neck, in order to return to the forehead or chin, 
as in the same figure. 

Use. — To retain dressings to the whole face, in 
cases of burns from blasting rocks, gunshot-wounds, 
erysipelas, small-pox, &c, in all of which it will be 
found to be a most useful bandage. 

THE SLING OF THE MAMMiE 

Is made of a square piece of muslin sufficiently large 

Fig. 88. 




to cover in the breast ; slit for one inch and a-half on 
each of its four sides, and of four bands sewed to its 



132 SLINGS. 

four angles. These bands must be long enough to 
go round the chest. Now whilst an assistant sup- 
ports the breast or retains the dressing, place the 
body of the sling on the part, and carry the lower 
tails under each axilla. Come round in front of the 
chest, and carry the upper tails on each side of the 
neck, over the shoulder, and fasten them to the hori- 
zontal band. 

Use. — To retain a poultice or other dressing to 
the breast, or to support it, as in cases of cancer, 
&c. ; but if compression is required, the Crossed of 
the Breast answers better. 

This, or the Four-tailed Sling, may also be use- 
fully employed in retaining dressings to the point of 
the shoulder ; the elbow ; back and front of wrist ; or 
to the heel and instep. In either of these cases, 
place the point to be covered in the centre of the 
body of the sling, and carry the tails round the part, 
so as to fix the bandage firmly. 



CHAPTER IX. 

OF SUSPENSORIES, SHEATHS, AND LACED 
BANDAGES. 



Suspensories are bags of certain sizes, intended to 
support depending parts, retain dressings to them, 
or cover such portions as would not otherwise receive 
a bandage. In all such cases they will be found of 
great service, and as their manufacture is simple it 
is surprising that they have not obtained a more gene- 
ral use. As adapted to the nose, &c, I can highly 
recommend them, to those requiring a complete band- 
age for such parts. 

THE SUSPENSORY OF THE NOSE 

Is used to retain dressings to the whole of this organ, 
and is composed of 
a triangular piece, Fi 9- 89. 

cut from an oblong 
square as in the 
dotted lines B C, and 
C D, of Fig. 89, to 
the sides of which are 
attached the vertical 
and horizontal bands 
of a single T. In 
applying the band- 
age, place the nose 
within the suspen- 
sory, and carry the 
vertical band over the head to the neck, confining it 
by the horizontal bands, which are crossed on the 
nucha; brought up on the forehead, and fastened 
12 




134 



SUSPENSORIES, SHEATHS, 



Fig. 90. 



as seen in the cut. The opening at A is to suit the 
position of the nostril. 

THE SUSPENSORY, OR BAG-TRUSS OF THE SCROTUM, 

As found in the shops, consists of a network bag and 
bands to fasten it (Fig. 66) ; but as this cannot always 
be had, its place may be readily supplied by one 
formed as follows, the application of both being the 
same. Fold a piece of muslin on itself, of a size to suit 
the part, say six inches by four, and cut out an open- 
ing, A, for the penis, and a curvilinear portion accord- 
ing to the dotted line, B C (Fig. 97). Sew the divided 
edges of this curved portion 
together, and attach a hori- 
zontal band, D, to the upper 
part, and two vertical ones, 
E F, to the lower posterior 
angle, making an opening or 
button-hole in the end of each 
band. Sew on two buttons to 
the horizontal band, to serve 
for the attachment of the ver- 
tical or perineal straps. Then 
the penis being engaged in 
the opening, A, and the 
scrotum perfectly enveloped, 
the belt should be carried 
round the pelvis ; returned in front, and tied above 
the pubes. The two vertical bands are then made 
to ascend from the perineum along the inferior border 
of the glutei muscles, and buttoned to the belt in 
front. 

Use. — To support and confine dressings upon the 
scrotum, or to serve as points of attachment to other 
apparatus, or for the treatment of swelled testicle, 
hydrocele, and irreducible scrotal hernia. This band- 
age should, also, always be worn during the treatment 
of acute gonorrhoea, as it diminishes the liability to 
epididymitis. 




AND LACED BANDAGES. 135 



SHEATHS 



Are coverings intended to retain dressings to the 
penis, fingers, and toes. They are the finger-stalls 
of domestic use, and employed daily by every one 
who has a cut finger. A very useful application of 
them by the surgeon can be made in cases of gonor- 
rhoea, as when made of large size they will readily 
retain a portion of charpie on the head of the penis, 
and by absorbing the discharge prevent its staining 
the linen. They are also very useful in retaining 
poultices to the head of the penis, or dressings to 
chancres, &c, in consequence of their not being 
easily deranged by erections. The band in such 
cases passes round the hips, as it does around the 
wrist when applied to the finger. 

THE LACED OR BUCKLED BANDAGES 

Are so named from the manner in which they are 
confined to the part. As they are usually obtained 
from the glovers, or bandage makers, I shall only 
refer to them in passing. Their application being 
very simple, and the discovery of them somewhat 
ancient, their use is generally understood. 

THE LACED BANDAGE FOR THE KNEE 

Is made of any elastic substance, such as buckskin 
or kid, lined with caoutchouc, &c, 
and laced at the side, as seen in Fi 9- 91. 

Fig. 91. It is sometimes employed 
where constant compression is re- 
quired, as after dislocations of the 
patella ; in chronic enlargements of 
the joints, &c. When wanted they 
should be made to order, as their 
utility depends on the accuracy 
with which they fit. They may be 
found at the cutlers, or druggists, 
generally. 




136 



LACED BANDAGES. 



Fig. 92. 



THE LACED STOCKING 

Is employed in the treatment of varicose veins ; 

for the support of tender and extensive cicatrices 
of the leg ; and in old ulcers, 
&c, being occasionally prefer- 
able in these cases to the ordi- 
nary bandage, as it presses uni- 
formly throughout its whole ex- 
tent; may be readily applied 
by the patient, and "worn under 
a boot. Where this bandage 
cannot be obtained ready made, 
slit a common strong cotton 
stocking down the side, and 
hem in on each edge a very 
thin slip of whale-bone. Then 
work a few eyelet-holes along 
the edges behind the bones, as 
in the corsets of the female, and 
fasten it up by lacings (Fig. 92). 




THE LACED GAITER FOR THE FOOT 



Fig. 93. 




Is constructed like the knee- 
cap, of buckskin, cloth, kid, 
and laces along the outside 
of the foot and ankle, as in 
that daily worn over a shoe. 
It serves admirably for support- 
ing the parts after sprains, or 
weakness of the lower portion of 
the leg and foot ; in the cure 
of old ulcers on the malleoli, 
and of oedematous swellings of 
the ankle generally (Fig. 93). 



PART SECOND. 



CHAPTER I. 

OF THE HANDKERCHIEF SYSTEM OF M. MAYOR, OR 

THE SYSTEM OF PROVISIONAL DRESSINGS. 

Before taking up the consideration of bandages 
as applicable to particular injuries, it will not per- 
haps prove uninteresting to examine the provisional 
system of M. Mayor, or the system in which he 
proposes and practices the employment of such sim- 
ple means as are always at hand, or which may often 
supplant, with advantage, the means already men- 
tioned, and supply their place whenever they cannot 
be obtained. " The more readily we can procure 
such means, the greater also their simplicity and 
uniformity, the less embarrassing will it be for the 
surgeon to fulfil his duties, the less perilous will be 
the progress of the treatment, and the less doubtful 
the chances of its termination. These observations 
apply with particular force to the circumstances in 
which surgeons are often placed, especially when 
practising among the poorer classes, in the country, 
in thinly-peopled districts, or in the army or navy, 
where hospital stores have failed or are rapidly 
diminishing." In doing this, M. Mayor has. made 
such a simplification of surgical apparatus, that 
under any, even the most disadvantageous circum- 
stances, relief may be afforded, and a plan of cure 
12* 



138 HANDKERCHIEF SYSTEM 

employed as safe and as commodious as that gene- 
rally recommended. 

The principle he has laid down is, to use his own 
words : — " To reduce as much as possible all kinds 
of apparatus to their most simple principles, by 
making them dependent upon particular and uniform 
ideas : in order that the parts of such apparatus, or 
the material objects of any dressing, may be so 
common, and of such a nature, as to be met with 
under every or nearly every circumstance, no less 
at the disposition always of the surgeon than of 
other persons ; and that, in the absence of a scientific 
man, they may be applied with facility by the first 
comer, after very little instruction. In other words, 
to find out a means, simple, easy of application, ever 
at hand, or at least always to be obtained, which 
may replace lint, compresses, bandages, and liga- 
tures, such as surgery ordinarily requires for the 
various species of dressings." 1 

This principle, which is certainly correct, is the 
one M. Mayor has the credit of prosecuting to per- 
fection, although for many years exposed to the 
sneers and ridicule of his professional brethren. As 
his plan of treatment is daily becoming better known, 
his system is now meeting with the respect to which 
by its merits it is entitled. 

As it would be impossible, in my present limits, to 
treat at length of all this surgeon's objections to the 
common modes of dressing and bandaging, or give 
t he fullest details of his method of treatment, I will 
only refer to the more interesting of his matter, be- 
lieving that many valuable hints may be derived from 
it, even by those who would not feel inclined to 
abandon altogether the older and more scientific 
methods employed in the treatment of surgical 
accidents. 



ysteme de Deligation Chirurgicale, Paris, 1838, p. 16, 
Introduction. Troiseme edition, avec un Atlas. 



OF M. MAYOR. 139 

* It has not been M. Mayor's object, as he expressly 
says, " to banish wholly from the domain of surgery, 
charpie, lint, bands, &c, notwithstanding that such 
would be rigorously possible ; but he has been so 
often struck with their abuse and their almost exclu- 
sive employment, that he could not forbear exposing 
their numerous inconveniences in practice, and en- 
deavouring to establish his own motives for what he 
admits to be their quasi- exclusion." 

The principal objection which he makes to the 
common bandage, "is in relation to its frequent 
absence in time of need; the occasional impossi- 
bility of procuring it, and the serious inconveni- 
ences with which its application may be attended 
when performed by unskilful hands ; for even under 
the best opportunities the habit of applying a band- 
age requires time, and is susceptible of being 
speedily lost. Bandages, also, are liable to become 
relaxed, easily deranged, and corded, thus inflicting 
injury in a variety of ways, and rendering their fre- 
quent re-application a matter of essential necessity ; 
their diversity of length and breadth is also more or 
less perplexing to some ; to roll them well is trouble- 
some ; and when to these well-founded objections to 
their exclusive employment is added the difficulty of 
having them always clean and neat, as well, also, as 
the little care that patients take of them when they 
are not absolutely wanted, it must be evident that 
some other means are requisite to rid the surgeon 
of so many causes of vexation and embarrassment; 
and that, when such are found, they must be hailed 
by the profession with something like satisfaction. 

" Now, all the inconveniences here spoken of may 
be avoided; and all the good desired obtained, from 
a bandage either of the original form of a cravat or 
pocket handkerchief, or of the principal modifica- 
tions of this, adapted to the nature of the case." 
M. Mayor makes four modifications of a handker- 



140 HANDKERCHIEF SYSTEM 

chief or cravat-shaped piece of linen, subservient to 
all the objects of a bandage ; such as the Oblong y 
the Cravat-shaped, the Triangular, and Cordiform 
handkerchief ; the latter being only employed as a 
substitute for a cord, or strong tie, in certain cases. 

None of the objections made to the ordinary band- 
age can, M. Mayor thinks, be applied to the hand- 
kerchief. " It is found everywhere, and under every 
circumstance ; is adapted to its purpose ; is not 
liable to become relaxed or otherwise deranged, and 
cannot become corded ; it is easy to fasten ; may be 
changed and reapplied with the utmost promptitude, 
as a single circumvolution of it is often equal to a 
multitude of turns of the common band ; is also 
more economical, as it may always be washed, and 
made ready to apply to other than to surgical pur- 
poses ; the thickness and breadth can be varied at 
will : in short, it is so much the more perfect as it 
forms one whole, while each turn of a common band, 
being considered as a piece apart, the derangement 
of one necessarily entails the derangement of all the 
rest." 

It is not, however, pretended by him, that this new 
description of bandages can supply, completely, the 
place of common rollers ; for, as he justly observes, 
"there are cases which require a methodic com- 
pression of a certain energy, such as affections of 
the mammae and of the extremities. But as these 
are comparatively rare, handkerchiefs should be 
employed as a general rule, while rollers should 
form but the exceptions. 

In the application of the handkerchief, or trian- 
gular piece of linen, M. Mayor commences at the 
head, and then, as in the present arrangement, pro- 
ceeds regularly on to the trunk and extremities. In 
pursuing this course he designates his handkerchief 
bandages by certain names, which may at first sight 
appear to be unnecessary and pedantic. But when 



OF M. MAYOR. 



141 



it is recollected that the arrangement of the name 
shows the course to be pursued in the application of 
the handkerchief, it will be seen that its name is a 
matter of considerable importance, and that it aids us 
materially in their application ; thus, in the Fronto- 
Occipital Triangle, we have the shape of the hand- 
kerchief, and the statement of the fact that it is to 
be first applied to the forehead and then to pass to 
the occiput; so in the Fronto-Cervico Labialis 
cravat, or the Occipito- Sternal, we know that the 
cravat should cover, first the forehead, then the 
neck, then the lip ; whilst the other should start at 
the occiput and end at the sternum. 

THE HANDKERCHIEF, OR SQUARE LINEN, 

May, according to M. Mayor, replace all the bandages 
of which I have be- 
fore treated. In its Mg.te. 
dimensions, as well 
as in the tissue com- 
posing it, the sur- 
geon must be regu- 
lated by the size of 
the part to which 
it is to be applied, 
or the circum- 
stances of the mo- 
ment. It is, there- 
fore, a matter of 
indifference whether the handkerchief be of silk, cot- 
ton, or linen. If it is too short to go round a part 
at the time of its application, it may be easily length- 
ened by attaching to the extremities two pieces of 
tape or ribbon. 

From this original piece he forms all the others, by 
folding it according to the dotted lines of Fig. 94 ; 
thus, if the four angles are folded into the centre, g, 
it makes a smaller square, which may be again *re- 




142 



HANDKERCHIEF SYSTEM 



duced by repeating the process. In this shape it 
answers very well for the application of warm foment- 
ing poultices, which may be thus easily retained be- 
tween the two layers of the handkerchief. If the 
square handkerchief is folded from angle to angle 
it forms a 

TRIANGLE. 

This triangle must vary in size according to the part 
to be covered by it ; though the largest of those em- 
ployed at Lausane is about a yard in length, and a 
half yard from its summit to the centre of its base. 
When it is wished to have a smaller triangle, divide this 
according to the line c d, or cut off portions on each 
side. Thus formed, the parts of the triangle are 
the Base, a, b ; the Angles or Extremities, or points 
of these same letters ; and the Summit, c. In order 

Fig. 95. 




to apply it, hold the handkerchief smoothly by the 
base, placing the thumbs above or on the upper sur- 
face, and the fingers widely extended on its under 
surface ; then apply the base first, and carry the 
extremities around the part so as to cover in the 
summit, making folds or plaits in any portion that 
may project. 

The Oblong Square, as seen in Fig. 94, does not 
require explanation, as it is readily seen to be formed 
of the common square doubled once on itself. 

The Cravat, Fig. 95, is so well known as also 



OF M. MAYOR. 143 

to require no explanation, the shape being that 
which is daily employed in arranging the covering to 
our necks. Like the triangle, the body, or base, a, 
of the cravat is the part first applied, and this is 
retained in its position by attaching the ends, b e, 
to the other parts of its body. 

The Cord is made by twisting a cravat on itself. 
It is of great utility in compressing vessels, espe- 
cially in the Garotte or Spanish windlass, which 
on an emergency will be found to be a good substi- 
tute (see Hemorrhage) for the ordinary tourniquet. 



CHAPTER II. 

OF THE HANDKERCHIEFS AS APPLIED TO THE 
HEAD. 



The first application of the handkerchief is to cover 
in the whole head, and is called 

THE SQUARE CAP OF THE HEAD. 

Form the handkerchief into an oblong square, and 

let the edge of the 
■%• 96 - side to go next the 

head be two inches 
shorter than the 
other. Draw the ends 
of the long side 
down the sides of the 
face, and tie them 
under the chin ; then 
draw the inner ends, 
or those of the short 
side forward, to free 
them from the former, 
and then folding them 
backwards, tie their 
ends on the occiput. 

Use. — To cover in the head, ears, and jaw. 

IN THE FRONTO-OCCIPTAL TRIANGLE 

The base is placed before the forehead, higher or 
lower, according to circumstances, whilst the lateral 
angles or tails are crossed at the occiput, and then 
brought forward as far as the temporal regions, or 




HANDKERCHIEFS AS APPLIED TO THE HEAD. 145 



on to the forehead, where they are fixed by means of 
pins. 



Fig. 97. 



i. 97. 




The summit is then turned over and fastened at 
the occipital region, by being made to pass under 
the angles, whence it is reflected upwards and pin- 
ned, as in Fig. 98. 

Fig. 98. 




Use. — To retain dressings to the head. 

FOR THE OCCIPITOFRONTAL TRIANGLE 

Place the base at the occiput ; cross the tails upon 
13 



146 



OF THE HANDKERCHIEFS 



the forehead, and pass the summit underneath the 
frontal portion so as to reflect it upwards. 

Use. — Same as the former, but more useful when 
pressure may be required on the forehead, as by 
crossing the angles, or by knotting them, consider- 
able force may be used. 

IN THE BITEMPORAL TRIANGLE 

The base is placed upon one of the temples, and the 
summit turned over towards the opposite ear and con- 
fined by the angles carried around the head. 
Use. — To retain dressings to the temples. 

THE SIMPLE OCCULO-OCCIPITAL TRIANGLE 

Requires that the base should be stretched obliquely 
from the superior part of the temporal region of the 
sound side, over one eye, to the sub-mastoid region 
of the diseased side ; the summit being carried diago- 
nally backwards to the posterior portion, where it 
crosses at the side of the neck corresponding with 
the sound eye. 

Use. — To cover in one eye. 



IN THE FRONTO-OCCIPITO-LABIALIS CRAVAT 

Place the body against the forehead ; cross the tails 

on the nape of the neck, 



Fig. 99. 




and bring them forwards 
to either lip, where one 
is to be passed through 
a slit perforated near the 
extremity of the other. 
These extremities being 
then pulled in contrary 
directions, over the com- 
each side of 
and secured 
by a couple of small pins 
or a few stitches under 
the ears, complete the 



presses on 
the wound, 



AS APPLIED TO THE HEAD. 



147 



bandage. If a triangular handkerchief is used, the 
summit should be carried to the occiput, passed under 
the first inter-crossing, reflected upwards and pinned, 
as Pig. 99. 

Use. — To sustain the union in wounds of the lip, 
or after the hare-lip operation ; or to confine dress- 
ings, or unite wounds in the absence of other means. 

IN THE FACIAL TRIANGLE, OR MASK, 



handkerchief in triangle, 

Fig. 100. 




Place the base of the 
under the chin, the 
summit on the fore- 
head, and carry the 
angles over the ears to 
the vertex, where they 
may be crossed and 
brought on the fore- 
head, in order to con- 
fine the summit. Holes 
or slits are then to be 
made for the eyes, nose, 
and mouth. 

Use. — To retain dressings to the face. 

IN THE VERTICO-MENTAL CRAVAT 

The body of a broad Fig. 101. 

cravat is placed on the 

vertex, and the ends 

carried under the chin 

and fastened to the 

sides of the first turn, 

near the ears. 

Use. — To retain 
dressings under the 
chin, or to the base of 
the jaw. 

THE OCCIPITO-AURICULAR TRIANGLE 

Is made by the base being placed obliquely in front 




148 



OF THE HANDKERCHIEFS 



Fig. 102, 



of the injured ear, whilst the summit is carried round 

towards the same ear. One 
angle then going under the 
jaw of the side affected 
comes up in front of the 
opposite ear, where it 
makes a knot which ties 
under the ear, or turns 
around the other angle, so 
that the two may run round 
the head, one in front, the 
other behind, to tie on its 
side or on the jaw. 

Use. — To retain dress- 
ings to one ear, or to the 
angle of the jaw, without interfering with the oppo- 
site ear (Fig. 102). 




THE OCCIPITO- STERNAL HANDKERCHIEF 

Requires two handkerchiefs, one in cravat, the other 
in triangle. Place the base of the triangle on the 

Fig. 103. 




occiput, with the summit anteriorly, and bring the 



AS APPLIED TO THE HEAD. 



149 



tails down along the sides of the head and face, so 
as to fasten them to the front of a sterno-dorsal or 
dorso-thoracic cravat (Fig. 103). 

Use. — To unite wounds of the throat, and bring 
the head to the chest. 



THE FRONTO-DORSAL 

Is the reverse of the above. The base of the triangle 
is upon the forehead, the summit carried posteriorly, 
and the tails turned downwards and backwards, to 
be fastened to the back of a dorso-thoracic cravat 
(Fig. 104). 

Fig. 104. 




-Reverse of the former, or to unite wounds 
of the back of the neck, &c. 



IN THE PARIETO-AXILLARIS 



Place the base of the triangular handkerchief on one 
side of the head, with the summit carried to the 
13* 



150 



HANDKERCHIEFS OF THE HEAD. 



opposite side, and tie the ends to an axillo-acromial 
cravat, as in Fig. 105. 

Fig. 105. 




Use. — To bring the head to one side, as in wry- 
neck, spasm of the sterno-cleido muscle, &c. 



CHAPTER III. 

OF THE HANDKERCHIEFS AS APPLIED TO THE 
TRUNK. 



The first of these is very simple, and constitutes 

THE CERVICAL CRAVAT OF DAILY USE, 

It has the centre before the larynx, side of the neck, 
or cervical vertebrae, according to circumstances; 
constituting an anterior, lateral, or posterior cervi- 
cal cravat. 

Use. — As a retaining bandage for dressings applied 
to the neck. The peculiar shape of the neck, especially 
at its connection with the chest, is such as to require a 
bandage to be cut with a slope, like an ordinary neck- 
handkerchief or stock, 



Fig. 106. 



in order to fit it, unless 
we resort invariably to 
the simple handker- 
chief just mentioned. 
As this region will not 
tolerate compression 
without a risk of inter- 
ruption of the course 
of the blood in the 
head, the handkerchief 
generally proves the 
best method of retain- 
ing dressings to this 
part. 



IN THE SIMPLE BIS-AXILLARY CRAVAT 

Place the centre in the axilla of the affected side ; 




152 



HANDKERCHIEFS AS APPLIED 



cross the tails over the corresponding shoulder, and 
then carry them one before, the other round and be- 
hind the chest, to the axilla of the opposite side, 
where they are to be secured (Fig. 106). 
Use. — To retain dressings to the axilla. 

IN THE COMPOUND BIS-AXILLARY CRAVAT 

Place the centre of a cravat on the axilla of the sound 
side ; carry the tails obliquely upwards to the base 
of the neck at the opposite side, and fasten their ex- 
tremities; next, apply the centre of a second, and 

Fig. 107. 




smaller cravat, in the axilla of the affected side, and 
attach its tails to the corresponding portion of the 
first (Fig. 107). 

Use. — Same as former, but to both axillae. 



IN THE SIMPLE BIS-AXILLO-SCAPULARY CRAVAT, OR 
POSTERIOR 8 OF THE SHOULDER 

Place the centre between the scapula, carry one of 
the tails round the corresponding shoulder and 



TO THE TRUNK. 



153 



axilla. Fasten the extremity by strong stitches 
to the body of the cravat, 



and conduct the other 
tail under the corre- 
sponding axilla, and over 
the shoulder, toward the 
extremity of the first, 
upon which it should be 
similarly secured, as in 
Fig. 108. 

Use. — Same as the 
preceding. 

IN THE COMPOUND BIS- 
AXILLO-SCAPULARY CRA- 
VAT 

Knot together the two ex- 
tremities of a cravat about 



Fig. 108. 




Fig. 109. 




one of the shoulders, so as to make of it a loose ring : 
next, take a second cravat ; apply the centre of this 



154 



HANDKERCHIEFS AS APPLIED 



against the anterior face of the other shoulder, and 
conducting the tails one over the shoulder and the 
other beneath the axilla, let the first embrace the 
corresponding portion of the ring, in order that its 
extremity may be united with that of the second 
tail, which should be made previously to pass 
about the first, in the manner represented in 
Fig. 109. 

Use. — Same as the two preceding, but preferable 
to either, on account of the much greater power it 
may be made to exert. 

FOR THE DORSO-BIS-AXILLARIS 

Place one handkerchief in cravat round the chest 
under each axilla, and the other in triangle on the , 

back, with its base up- 
Fig- HO. wards. Fix the sum- 

mit of the triangle to 
the circular cravat, and 
carry the angles over 
each shoulder and 
axilla, to fasten to the 
circular handkerchief 
behind, and on the 
sides (Fig. 110). 

Use. — To retain 
dressings to these 
parts. If the summit 
is fixed to the circular 
cravat in front, and 
the angles brought 
over each shoulder to 
fasten behind, it will retain dressings to the front of 
the chest, and form a Cervico- Thoracic Handker- 
chief. 

IN THE TRIANGULAR CAP OF THE BREAST 

Place the base of a triangle obliquely across the chest 




TO THE TRUNK. 



155 



under one breast, with the summit over the corres- 
ponding shoulder ; and carry one angle over the op- 




posite shoulder, and the other under the correspond- 
ing axilla, to tie on the back of the shoulder. Then 
confine the summit. 

Use. — To retain a dressing to, or support the breast 
during lactation, &c. 

IN THE SUB-FEMORAL HANDKERCHIEF 

One handkerchief in cravat goes circularly around 
the pelvis. The base of another, which is in trian- 
gle, is applied obliquely on the thigh, the angles 
passing circularly around its upper part, and the 
summit obliquely up between the nates, to be fixed 
to the circular band, as at A, Fig. 112. 

Use. — As a means of covering the pelvic portion 



156 



HANDKERCHIEFS AS APPLIED 



of the body, and the only one that does it with neat- 
ness and accuracy. 

Fig. 112. 




THE INTER-FEMORAL HANDKERCHIEF 

Requires the base on the back of the body ; the an- 
gles brought round the pelvis ; and the summit to be 
carried over the perineum, to fasten to the angles 
in front, as in the diapers of children. 



TO THE TRUNK. 



157 



IN THE SINGLE SPICA 

Place the body of a cravat in 
the line of the groin and 
carry one extremity around 
the pelvis, the other around 
and below the thigh, to meet 
it on the groin. If not long 
enough, attach tapes to the 
extremities. 

Use. — To retain a dressing 
to one groin. 



Fig. 113. 




FOR THE DOUBLE SPICA 



Fold two handkerchiefs in cravats, and tie an extre- 
mity of each together. Place 
the knot a little on one side 



Fig. 114. 



of the spine, and carry the 
other extremity of each, 
round over either innomina- 
tum, in the line of the groin, 
between the thighs, and 
round their outside, to come 
up and fasten to the bodies 
of the cravats. 

Use. — To retain dressings 
to both groins. 




TO MAKE THE SUSPENSORY OR SCROTO- LUMBAR 
TRIANGLE 

Form a lombo-abdominal cravat for a belt, and apply 
the base of a triangle to the under and back part of 
the scrotum. Carry the tails to the forepart of 
the belt; pass them about this, from before back- 
ward, as represented in Fig. 115, and tie the ex- 
tremities, so as to bring the knot in front, and 
prevent its chafing. Next carry the summit up- 
14 



m 



158 



HANDKERCHIEFS FOR THE TRUNK 



wards, pass it under the transverse portion of the 
tails and under the belt, reflecting it over the fore- 
part of the handkerchiefs, so as to secure it with 
a pin. 

Fig. 115. 




Use. — To support the testicles, large scrotal hernia, 
&c, &c. 



CHAPTER IV. 

OF THE HANDKERCHIEFS OF THE UPPER 
EXTREMITIES. 



The handkerchiefs of the Upper Extremities are an 
excellent class of bandages, and may frequently sup- 
plant the ordinary roller with advantage. 

THE CERVICO-BRACHIAL SLING. 

Is made by placing one handkerchief in a cravat 
around the neck, 



Fig. 116. 



and knotting its 
ends over the ster- 
num. Place the 
other in a triangle 
under the forearm, 
so that its base may 
be next the wrist; 
then tie its angles 
to the cravat, and 
carry the summit 
around the elbow to 
fasten it to the body 
of the triangle in 
front. 

Use. — To support the forearm. This method of 
forming a Sling is better than the common plan, as 
the knots do not cut the back of the neck, owing to 
the position of the cravat, whilst the summit of the 
triangle, being fixed at the elbow, keeps the arm 
more closely to the side of the body. 

THE ANTE-BRACHIAL TROUGH 

May be constructed either of leather or pasteboard, 




Fffffl 



160 



OF THE HANDKERCHIEFS 



Fig. 117. 



which latter may be covered by some appropriate 
material with the view of preserving its form, or 
even giving it a sort of embellishment. It may be 
either straight, that is to say, open at the level of the 
elbow, or, as represented in Fig. 117, terminating 
there in a cul-de-sac. A long riband or cord is re- 
quired to serve for its suspension, and constitute two 
collateral bows to which the author applies the term 
arc-loops; — lastly, a cravat, so arranged as to con- 
stitute a Cervical Cravat. 
Four holes being previ- 
ously bored through the 
trough at convenient dis- 
tances apart, near its 
borders, the cord is run 
through them, in order to 
form the loops, which in 
their passage should be 
made either to glide 
through the Cervical Cra- 
vat, as represented in 
Fig. 117, or what is bet- 
ter, through a ring, which 
serves to connect them, 
and allows of a free play of the loops ; from this the 
patient will derive no small convenience. When the 
apparatus is thus prepared, nothing remains to be 
done but to introduce therein the patient's forearm, 
which has been, if fractured, previously furnished 
with its bandage. 

Use. — This apparatus may be worn enclosed in 
the patient's ordinary dress, so as not to give the 
appearance of the arm being subjected to confine- 
ment. But if it be required to preserve the elbow 
fixed against the trunk, a riband must be made to 
pass through a couple of holes perforated in the in- 
ternal portion of the trough, or that which corre- 
sponds to the body, and embrace the trunk, as a 




OF THE UPPER EXTREMITY. 161 

belt or body-bandage. If it be necessary to give 
support to the hand or wrist, a thin, flat piece of 
wood may be laid at the bottom of the trough, and 
its projection beyond the end of the latter regulated 
by circumstances. 

IN THE TRIANGULAR CAP OF THE SHOULDER 

Place the base of the triangle at -%• 118 - 

the insertion of the deltoid muscle, 

or elbow ; carry the summit over 

the acromion, and the angles round 

the arm, tieing them on it as in 

Fig. 118. 

Use. — To retain dressings to the 
round part of the shoulder or middle 
of the arm, which it does very per- 
fectly. 



IN THE TRIANGULAR CAP OF THE HUMERUS AND OF AM- 
PUTATIONS 

The base of a triangle is to be placed under the 
limb, at a convenient distance from the extremity 
of the stump ; the tails are then to be brought for- 
ward and overlapped, and the summit carried over 
the stump and fastened to the circular portion, or 
the angles. In this last part of the process take 
care that the handkerchief or linen embraces, very 
accurately, the extremity of the stump, as shown at 
page 37. 

Or, instead of commencing with the lateral angles, 
the summit may be first carried upwards in the man- 
ner described, and then the tails, in encircling the 
limb, be made to include its extremity. 

Use. — Whether employed in amputations of the 
upper or lower limbs, of the fingers or toes, or even 
of the penis, nothing can be more simple or more 
14* 




162 OF THE HANDKERCHIEFS 

effectual than this bandage. In general, no further 
precaution is necessary than to insist upon the pa- 
tient remaining quiet ; for if the bandage be care- 
fully applied there will be hardly a possibility of 
any derangement. But should it be absolutely ne- 
cessary to have recourse to some expedient to pre- 
vent the apparatus from becoming detached, a cravat 
belt may be applied about the neck, or pelvis, 
the lower part of the arm, or thigh, the wrist, or 
ankle, according to the seat of operation, and the 
limb be fastened to this by bands or tapes. 

IN THE CARPO-OLECRANIEN 

Fold two handkerchiefs into cravats, and apply one 
circularly around the arm above the elbow. Then 
tie an extremity of the other around the articulation 
of the carpal and metacarpal bones, so that the knot 
may come on the back of the hand, and attach the 
other extremity to the circular cravat, as in the arm 
of Fig. 112. (B.) 

Use. — To keep the forearm extended. When a 
splint is passed under each handkerchief on the front 
of the arm it answers very well in the latter stages 
of fracture of the olecranon. 

IN THE FLEXOR OF THE WRIST 

Fig. 119. Place a cravat circularly round the 

arm above the elbow, and a trian- 
gle around the hand so that the 
summit may be folded over, and' 
fastened by one angle around the 
wrist. Flex the hand and fore- 
arm, and attach the other angle 
to the cravat on the front of the 
arm, as in Fig. 119. 




OF THE UPPER EXTREMITY. 



163 



FOR THE CARPO DORSAL, OR PALMAR TRIANGLE, 

Place the base of a triangle on the dorsal or palmar 
surface of the wrist, and carry the angles round this 
and the summit over the fingers, which should be 
flexed, as in Fig. 120, 
if a dorsal handkerchief Fig. 120. 

is wished. If not, slit 
holes in the handker- 
chief, as in the perfor- 
ated T of the hands, 
and passing the fingers 
through them attach the 
summits to the angles. 

Use. — To retain dressings to the back or front of 
the hand, or between the fingers. 




CHAPTER V. 

OF THE HANDKERCHIEFS OF THE LOWER EX- 
TREMITIES. 



Fig. 121. 



These hankerchiefs supply a covering for parts that 
often embarrass the practitioner to retain dressings 
on, by any other means. The first is : — 

THE METATARSOMALLEOLAR CRAVAT. 

Place the body of the cravat obliquely across the 
instep, and carry one ex- 
tremity round above the 
malleoli, the other round 
the sole of the foot and in- 
step, to join it on the front 
of the ankle. 

Use. — To retain dress- 
ings to this part, as after 
tying the anterior tibial 
artery. But where pressure 
is required, the spica of the 
instep should be substituted. 

TO MAKE THE TRIANGULAR CAP OF THE HEEL 

Apply the base of a triangle to the sole of the foot, 
directly under the instep ; carry the summit over 
one malleolus ; cross the angles on the instep, and 
then carry them around the malleoli to confine the 
summit, as in the foot of Fig. 122. (A.) 

Use. — To retain dressings to the heel. This is 
an excellent bandage in the treatment of the excori- 
ations often consequent on the use of the extending 
band in the treatment of fractures of the thigh. 




OF THE HANDKERCHIEFS, ETC. 



165 



THE TARSO-PELVIEN CRAVAT 

Eequires one circular cravat around the pelvis, and 
the body of a second on the top of the foot, with one 
end tied under the sole and the other fastened to 
the pelvic band, as at B. 

Fig. 122. 




Use. — To support the limb and keep the foot ex- 
tended, as in ruptured tendo-Achillis. 

THE COMPOUND METATARSO-ROTULAR CRAVAT 

Is composed of four cravats ; — a hollow pasteboard 
or split deal splint, and some soft compresses. Then 



166 OF THE HANDKERCHIEFS OF THE 

the patient's limb being placed in the most complete 
extension, and the heel kept elevated above the 
level of the tuber ischi by means of a pillow, the 
centre of the first cravat is to be applied against the 
anterior part of the thigh, immediately above the 
patella, and its extremities carried backward, crossed, 
and returned to the anterior part of the leg imme- 
diately below that bone ; by drawing on these, the 
two broken surfaces will be placed in tolerable appo- 
sition. The centre of the second cravat should then 
be applied against the sole of the foot ; one extremity 
loosely knotted upon the metatarsus, and the other 

Mg. 123. 




subsequently carried upwards on one side of the knee 
to the supra-rotular portion of the first cravat, to 
which it is to be attached, as seen in Fig. 123. 
The sole of the foot here serves for a point of sup- 
port ; and this second cravat, aided by the respec- 
tive positions of the leg, of the thigh, and of the 
pelvis, tends to counterbalance the action of the 
extensors of the leg. But to obviate still more any 
possibility of flexion of the latter upon the thigh, 
which these cravats would not in all instances be 
enabled of themselves to counteract, recourse is had 
to a hollow splint, which is well lined with soft com- 
presses, and applied against the posterior surface of 
the limb. This is fastened in the simplest manner 
by the two remaining cravats. 



LOWER EXTREMITIES. 



167 



Use. — In fractured patella ; incised wounds of the 
knee, &c. 

THE TARSO-PATELLA CRAVAT 

Requires one handkerchief in Fi 9- 124. 

a cravat around the knee in a 
figure of 8, so as to embrace 
the patella ; the middle of an- 
other being under the instep, 
and one end tied on its out- 
side, the other passed under 
the cravat at the knee, as in 
Fig. 124. 

Use. — In fracture of the 
patella. 




IN THE MALLEOLAR PHALANGIAL TRIANGLE, OR CAP OF 
THE FOOT 



Place the base of a triangle un- 
der the instep ; carry the sum- 
mit over the toes ; and the angles 
around the malleoli, to enclose the 
whole foot. 



Use. 
foot. 



Fig. 125. 



•To retain dressings to the = 




IN THE TIBIO-CERVICAL CRAVAT, OR SLING, 

Apply the body of a cravat to the shoulder opposite 
to the side affected, and bring down the tails obliquely, 
to just above the crest of the ilium of the side cor- 
responding to the injury, so as to give it, when knot- 
ted, the appearance of a band. Then, flexing the 
leg to a right angle, apply a triangle on its anterior 
face, the base corresponding to the ankle, and the 



168 



OF THE HANDKERCHIEFS OF THE 



summit to the knee ; then carrying the tails, one 
along the inside and the other along the outside of 
the thigh, attach their extremities securely to the 
cervical cravat, near the pelvis. 

Fig. 126. 




Use, — To support the limb after the treatment of 



LOWER EXTREMITIES. 



169 



fractures of the leg, or in sprains, where the patient 
is desirous of walking about. 

IN THE TIBIAL CRAVAT 

Place the body of a broad ■%• 12 ?. 

cravat obliquely across the 

back of the leg, and carry one 

extremity round the leg below 

the knee, the other above the 

ankle ; to meet and tie, or pin, 

on the front of the calf, or spine 

of the tibia. 

Use. — To confine Sinapisms, 
Blisters, &c, to the calf. The 
figure of 8 turns of this hand- 
kerchief prevent its becoming 
deranged by the movements of 
the patient. 1 

BARTON'S HANDKERCHIEF. 

A very excellent method of making an extending 
band for the treatment of fracture of the thigh has 
been proposed by Dr. J. Rhea Barton, of Philadel- 
phia. Dr. Barton was led to this application of the 
handkerchief by seeing how well the pressure of the 
boot on the heel and instep was borne, and how fre- 
quently excoriation and troublesome ulceration of the 
heel followed the use of the ordinary band or gaiter, 
which pressed directly on the sharp edge of the tendo- 
Achillis. With these views, he folded a handker- 
chief into a narrow cravat, and placed the body of it 
directly on the extremity of the os calcis, below the 
tendo-Achillis, so that two-thirds of the cravat came 
round under the outer malleolus, and the other third 
remained on the inside. The inside portion remain- 




15 



Mayor' Nouveau System. 



170 



MAYOR'S SYSTEM 



Fig. 128. 



ing parallel with the sole of the foot, the outside 
piece was carried over the instep and passed round 
it, so as to form a sort of knot. 
Then passing under the sole of the 
foot it is turned around the first 
turn, and form another knot at 
the metatarsal articulation, when 
both ends are carried off perpen- 
dicularly from the foot and fast- 
ened to the splint, the pressure 
coming directly on the instep and 
point of the heel, as seen in Fig. 
128. 

When ulceration on the front of 
the ankle-joint, or on the heel, has 
been produced by the use of the 
ordinary means, this will be found 
to avoid the sore points, and yet 
keep up a permanent extension. 




I have now given an account of the manner in 
which the Handkerchief is frequently employed as a 
substitute for the ordinary roller; and therefore 
pass, in order to preserve the continuity of ideas, to 
the Hyponarthecia of Mayor, or peculiar means of 
treating fractures, as described in " Cutler on Band- 
aging, &c," including a detailed account of his Clini- 
cal Frame ; my wish being to offer as great a variety 
as possible, of the means of treating surgical injuries, 
in the belief that each one will take from them what 
is most desirable. 

" In 1812, Mr. Sauter published, at Constance, a 
work entitled ' Instructions for treating safely, corn- 
modi ously, and without splints, fractures of the ex- 
tremities, particularly the complicated ones, and those 
of the neck of the femur, by a method new, easy, 
simple, and economical.' This work, published in 



MAYOR'S SYSTEM. 171 

German, was somewhat voluminous ; and in order to 
render the subject matter more intelligible, M. Mayor 
translated freely whatever appeared to be the most 
prominent features of this novel invention, and pub- 
lished them in the work from which his system has 
been taken. Perceiving fully the advantages that 
might be derivable from the new system, he adopted 
it exclusively, and having submitted it to the test of 
fourteen years' experience and observation both in 
the Hospital of Lausanne and in his private practice 
in the Canton, which was very extensive, he pub- 
lished, under the title of 'Memoire sur l'Hyponar- 
thecia,' the various modifications he had deemed 
necessary to give to this mode of treatment its 
greatest efficiency. His reasons for adopting the 
term Hyponarthecie (»t«, under; v*/>fl»|j, splint) were 
based upon the fact that the j9?an^^e^e, or Scheb- 
machine, or support of M. Sauter, upon which the 
limb reposes, was in itself a splint. This term is 
expressive of the system, and has, therefore, been 
Anglicised. 

" To set out, the problem proposed by M. Sauter, 
a problem so difficult that it almost seems a parodox, 
but which he has ably resolved, was ' to treat a broken 
limb, with even the most serious complications, by 
position only, and without the use of splints ; and to 
permit the limb, at the same time, to execute, without 
pain or inconvenience, every movement parallel to 
the horizon.' 

"This apparatus consists in a board properly 
cushioned, upon which the injured limb should be 
placed and fixed in the position which it is necessary 
to give it. The board thus charged is attached to 
the ceiling or the top of the bed by means of cords, 
which are run through holes pierced in its borders 
and suspended above the bed, so as to render it freely 
moveable. For the purpose of fastening the limb 
two or three cravat-shaped ligatures are employed, 



172 MAYOR'S SYSTEM. 

which, in case of need, and with a certain modifica- 
tion of this apparatus, namely, a foot-board or ladder, 
will equally serve for the execution of traction or ex- 
tension. But these ligatures, besides fixing the limb, 
exert a specific action upon the fragments themselves ; 
for, acting in contrary directions, they keep the 
fractured ends of the bone themselves as well in 
juxtaposition as in the most complete immobility: 
so that this simple contrivance not only effectually 
produces the necessary traction in the axis itself of 
the bone, but even similar tractions directly trans- 
verse to it ; an advantage by which it is distinguished 
above all other apparatus for fractures. The state 
of immobility is importantly seconded by the soft 
cushion, which, by moulding itself to the form of the 
limb, guarantees the security of its under part, or 
that which alone can be said to be excluded from 
the direct action of the transverse ligatures. 

"But how, it may be asked, are the involuntary 
muscular efforts of the limb to be controlled ? The 
answer to this is, that they soon terminate even under 
ordinary circumstances, and they do so in this case 
so much the sooner, as they are not stimulated and 
kept up by the weight or offensive pressure of ordi- 
nary apparatus. 

"As the whole limb rests exposed to view, the in- 
spection of the practitioner will discover at once the 
slightest possible displacement, which he will be en- 
abled to remedy with the utmost facility; at the 
same time that he may employ every kind of thera- 
peutic agent in the event of injury of the soft parts. 
And the patients possessing, even under the most 
serious complications of their fractures, the faculty 
of horizontal motion, their beds can be easily made, 
and all the other necessary offices readily per- 
formed. 

"Not the least advantage peculiar to this appara- 
tus is its ready construction ; it may be made at all 



MAYOR'S SYSTEM. 173 

places and under any circumstances, even by the 
practitioner himself ; for if, viewing the materials in 
detail, some of these may not be at hand, such, for 
instance, as the pulley for the cords to run through, 
affixed to the ceiling, or the hinges necessary to a 
jointed board (see cuts), or a gimblet to bore the 
necessary holes, substitutes may be instantly found; 
as a staple for the first, a bit of strong leather for 
the second, and for the third a few nails, by which 
the cords may be effectually fixed to the edges of 
the board. So, also, with respect to the cushion, how 
many substitutes may be found for this ! In short, 
whether a surgeon be called for in scenes of the 
greatest poverty, on board ship with the fewest pos- 
sible resources, or in the wildest districts, he need 
never be embarrassed. 

" On board ship it is especially serviceable, as the 
fracture is not easily deranged by the motions of the 
vessel, owing to the limb being allowed to swing as 
well as the body. 

" The reduction of fractures by the employment 
of this suspension apparatus is effected thus: The 
board being furnished with its cushion, which should 
be sufficiently thick to constitute a soft bedding, and 
entirely cover it, and the vertical cord, forming a 
loop, properly suspended from the ceiling; the 
second cord, destined to form the side loops, or arcs 
of the board, is to be run through the holes perfo- 
rated through the angles of this, passing in its course 
through the first or suspension loop, so as to be in 
readiness to comply with any exigencies, in regard 
to length, when the suspension is about to be effected. 
This done, the limb is made to glide along the cush- 
ioned board; and then the resistance, or counter- 
extension and traction, is resorted to, together with 
the coaptation of the fragments ; and, by means of 
the traction-bands, the position and coaptation of the 
fragments is fairly established. The ladder or foot- 
15* 



174 MAYOR'S SYSTEM. 

board, or extension band, will now keep the foot 
steadily fixed, while the due elevation given to the 
centre of the jointed board, if this be used, will con- 
stitute it an excellent double-inclined plane, possessed 
of all the advantages accorded to that species of ap- 
paratus. Lastly, the arc-loops and suspension loops 
are to be regulated so as to raise the limb to a proper 
height, which will be judged of by the surgeon, in 
consulting at all times, however, the feelings of the 
patient. 

" As this kind of apparatus is in the way of the bed 
coverings, some little tact is requisite to overcome 
this trifling impediment; but nothing need be ob- 
served on the subject here, as the good sense of the 
practitioner will always readily suggest means to 
remedy an inconvenience so truly unimportant. 

" The use of the jointed board is strikingly evident 
in fractures of the femur, whether of its shaft or neck : 
ifc effects, in its quality of double-inclined plane, that 
which modem surgery only has succeeded in obtain- 
ing, namely, permanent Extension, joined to double 
Flexion, and the Fixing of the entire limb : but, be- 
sides this, suspension affords the utmost facility of 
motion in mass by means of lateral action. It will 
be only necessary to observe this apparatus, as illus- 
trated in the cuts, to be convinced how effectually 
the above important objects are attained, and how 
totally impossible it must be for the fragments of the 
bone to ride in cases of oblique fracture, by reason 
of the powerful aid of the pelvic bandages. 

"Even in fractures of the upper extremities the 
hyponarthecic apparatus may be sometimes advan- 
tageously employed ; as, for instance, where the frac- 
ture is one of very serious character, and complicated 
with injuries of the soft parts, which requires that 
the patient should keep his bed, and which precludes, 
from what cause soever, the application of ordinary 
apparatus, as tending to aggravate his sufferings, and 



MAYOR'S SYSTEM. 



175 



augment the difficulties of the case. In short, the 
only circumstances in which the invention of M. 
Sauter is contra-indicated are those in which infants 
or maniacs are concerned, for reasons which the least 
consideration will render apparent. 

THE ANTE-BRACHIAL HYPONARTHECIA 

" Consists in a board of convenient width, a little longer 
than the forearm and hand ; — a cushion ; a cord for 
arc-loops ; and three cravats. Then, the fracture 
being reduced, the forearm is made to repose on the 
cushioned board, a b, which is immediately put into 
suspension to the patient's neck by means of the arc- 
loops, e e, ring, /, and cervical cravat, g. The second 
cravat, c, is now passed under the wrist and crossed 
upon the back of the hand, the tails being then made 
to embrace the cushioned board, and knotted at its 
anterior border, as represented in the wood-cut. 

Fig. 129. 




That done, the third cravat, d, is made to pass round 
the apparatus at its upper part, so as to confine the 
corresponding part of the forearm, and be knotted 
also at its anterior border. Should it be deemed ex- 



176 MAYOR'S SYSTEM. 

pedient, a fourth cravat may be made use of, to serve 
for a traction-band, which will, of course, be knotted 
at the inner border of the suspension board. 

"The advantages that maybe derived from the 
hyponarthecic apparatus may here be judged of; for 
in cases of fracture complicated with laceration, or 
other injuries of the soft parts, even occurring at 
the upper extremities, the wounds remain under the 
constant inspection of the practitioner, and are not 
subjected to the incommodious and even dangerous 
pressure of the common bandage, as must be the case 
when recourse is had to it under such circumstances. 
The patient may even be permitted, by the employ- 
ment of this apparatus, to take exercise when the in- 
juries of the soft parts are not very grave ; but if, on 
the contrary, perfect repose be deemed essentially 
necessary, instead of the above apparatus a board 
should be procured, which, extending from the axilla 
to beyond the finger's ends, should be well cushioned, 
and maintained in place by means of a Bis-Axillary 
Cravat. The board may then be put into suspen- 
sion, and the above cravat adapted to suit the object 
in view in the following manner : — The centre of the 
cravat should be applied to the axilla of the sound 
side, its tails carried before and behind the chest to 
the opposite shoulder, crossed thereon, and then 
brought down, one on each side of the deltoid, to the 
upper part of the board, the extremities being made 
to pass through a mortise, perforated in each board, 
in order to be knotted underneath. 

" The bands for fixing, and the traction bands, 
may then be adapted according to the principles of 
the system. 

" With respect to the suspension, in such a case, 
it may be made either from the ceiling, or the top 
of an ordinary bed ; or if the hospital-bed be em- 
ployed, as described hereafter, from the Suspension- 
Bar attached thereto. A precaution perhaps not 



MAYOR'S SYSTEM. 177 

unnecessary to be given with regard to the cushion 
is, that this should be of sufficient length to allow of 
its being turned downwards at its upper part, in 
order to protect the axilla from the pressure of the 
extremity of the board." 

This last apparatus will, of course, be equally 
applicable to fractures of the humerus, if complicated 
with severe injuries of the soft parts, but where a 
carved splint, as spoken of hereafter, can be obtained, 
it offers such advantages as must prevent frequent 
recourse being had to this of M. Mayor. 

HYPONARTHECIA FOR THE TREATMENT OF FRACTURES 
OF THE LOWER EXTREMITY. 

" This consists of a straight board, furnished with 
a cushion, and suspended something in the manner of 
a scale-beam, from the ceiling or top of the patient's 
bed, by means of cords ; its object being to give support 
to a fractured limb, and allow of lateral movement. 

" The only thing which distinguishes this from 
other kinds of apparatus is the suspension. The first 
thing to be shown is the method of constructing it, 
and the advantages to be derived from its employ- 
ment; the next, its adaptation to the limb according 
to the nature of the injury. 

CONSTRUCTION. 

" A thin board must be procured, proportioned in 
length and breadth to the size of the limb, as in 
Figure 130; it should be a trifling degree broader, 
and a few inches longer than the limb. Thus, for 
fractures of the leg it should extend from the bend of 
the knee to three or four inches beyond the heel. 
This board should be covered by a cushion, of its 
own magnitude, made of oat-chaff, bran, cotton, hair, 
tow, or, in short, of anything that could answer the 
same purpose, and be readily procured : and it should 
have sufficient firmness to afford a plane of some 



178 



MAYOR'S SYSTEM. 



Fig. 130. 



resistance to the limb, and yet be capable of mould- 
ing itself exactly to its form. A hole is to be pierced 
near each of the angles of the board for the passage 
of the suspension cord, as at c. Each end of the 
cord is then to be introduced through the correspond- 
ing holes at one extremity of the 
board from below upward, and 
after being drawn to the same 
length, passed from above down- 
ward through the holes of the 
other extremity, and firmly knot- 
ted. The cord will thus form 
two parallel bows of equal length, 
which, by being held at the mid- 
dle, will suspend the board as a 
perfect plane, or allow of its re- 
ceiving more or less inclination 
either way, according to the dis- 
tance, on one side or other of 
the centre, upon which the point 
of support is made to act. The 
support here spoken of con- 
sists of another cord, one end 
of which is to be carried through 
a staple driven into the ceiling above the injured 
limb, and the other made to pass under the collected 
bows. By pulling, in contrary directions, the ex- 
tremities of this second cord, the board may be ele- 
vated to the necessary degree ; and by knotting them, 
the elevation thus obtained steadily preserved. 

"Instead of the staple it is better to employ a 
pulley, if it can be had, as seen in figure 131. A 
pulley would likewise be found more convenient for 
the connection of the perpendicular and transverse 
cords, as seen in the figure at B. The first of these 
pulleys will afford greater facility in the elevation of 
the board, while the second will serve to give it the 
due degree of inclination with but little effort, and 
without occasioning the slightest shock. 




MAYOR'S SYSTEM. 



179 



"As the free sliding of the cords would be detri- 
mental to the treatment of this case, from the cir- 
cumstance of the board being liable to alter its posi- 
tion by the least movement of the patient, it is ad- 
visable to tie the two bows together near the pulley, 
and introduce between the latter and the ligature a 
small splinter of wood, which will naturally prevent 
the bows from retrograding. 

Fig. 131. 




" These preliminary arrangements, with the ex- 
ception of the introduction of the splinter, or foot- 
board, should be made before the limb is placed 



180 MAYOR'S SYSTEM. 

upon the board, in order that it may be immedi- 
ately elevated when the former is applied upon the 
cushions. Care also should be taken to arrange 
beforehand the patient's bed, by pressing it down 
at the part corresponding to the apparatus, in order 
that his horizontal movements may not be inter- 
rupted. As soon as the limb has been elevated to 
a certain height, it is advisable to place a pillow un- 
derneath the board, which should remain there till 
the fracture is reduced, and the position, &c, of the 
limb conveniently arranged. This apparatus, when 
isolated, yields to the slightest impulse imparted by 
the patient in his movements, without occasioning 
either shock or pain. 

" The facility which patients have of moving them- 
selves in this way is so great, that, as M. Mayor has 
remarked, they may be seen changing their position 
with the utmost facility, obeying, through means of 
the common utensils, the calls of nature, and even 
gliding upon another bed of equal height. 

" Nevertheless, as may be readily conceived, it 
would be imprudent to permit them to indulge in 
any inconsiderate movements, as this would occasion 
and keep up in the osseous fragments a mobility that 
would become an obstacle to their consolidation. 
When, therefore, it is found impossible to suppress 
the indulgence of such imprudent movements, the 
surgeon must have recourse to the bandage of Scul- 
tetus, with the aid of splints, or else to the carved 
splint, to be spoken of farther on. 

" It may thus be seen, that in fractures of the leg, 
where the suspension apparatus presents the most 
advantages, a simple board suffices, if it extends from 
the bend of the knee beyond the heel. A simple 
board arranged in the same manner, and which, de- 
parting from the tuberosity of the ischium would 
pass a few inches beyond the heel, would also be 
equally sufficient for a fracture of the shaft of the 



MAYOR'S SYSTEM. 



181 



femur, if it was considered proper to place the limb 
in an extended position, upon its posterior face ; but 
for those surgeons who prefer the demi-flexion of the 
leg upon the thigh, and the latter upon the pelvis, 
the following apparatus becomes indispensably neces- 
sary: Two boards must be procured, the one pre- 
cisely similar to that called tibial, of which mention 

Fig. 132. 




has been already made and represented in Fig. 131 ; 
the other femoral, as in this figure, extending from 
16 



182 MAYOR'S SYSTEM. 

the ham to the ischiatic tuberosity, and articulating 
with the preceding, either by means of hinges or 
simple tapes, which should pass through the holes 
with which the extremities of these boards are pierced, 
and be knotted underneath. The suspension of this 
double inclined plane is effected in the same manner 
as the simple tibial board, with this difference only, 
that the two bows are extended from the superior 
extremity of one of these boards to the inferior ex- 
tremity of the other. But in order to form the two 
inclined planes which are to support the limb in demi- 
flexion, a small cord should be passed from below 
upward, through one of the holes of the upper ex- 
tremity of the tibial board, as in the figure, across 
the point of support, and thence, from above down- 
ward, through the other hole of the same extremity, 
under which the two ends should be knotted together. 
In this way, the extremities of the two boards, cor- 
responding to the bend of the knee, may be made to 
describe an angle, more or less acute, according as 
the limb is required to be placed in a greater or less 
degree of flexion. 

" When position alone is sufficient to maintain 
the fractured extremities of the bone in apposition, 
and it is indispensably requisite to exert continued 
extension, or, in short, when more solidity is required 
to be given to the apparatus, the femoral board 
should be shaped out at its internal and superior 
angle, and furnished with a belt, which will be spoken 
of farther on. 

"The boards thus arranged are not only useful in 
fractures of the shaft of the femur, but also in the 
treatment of fractures of the neck of that bone ; as 
they fulfil perfectly, in presenting two inclined planes 
for the flexion of the thigh and leg, the indication of 
the pillows of Sir Astley Cooper, and the machines 
of Sir Charles Bell, Earle, Delpech, &c. ; which have 
the inconvenience of being much more complicated, 



MAYOR'S SYSTEM. 183 

and consequently of less easy and general applica- 
tion, particularly in places distant from large towns. 
In short, one of the advantages for which the sus- 
pension apparatus is deserving of being made known 
is its simplicity, and its possibility of being con- 
structed at all times, and in all places. In country 
practice, says M. Mayor, in isolated districts, every 
portion of this apparatus may be readily procured 
without occasioning the least embarrassment to the 
surgeon. 

"For myself, I may say," continues this gentle- 
man, " I have never experienced the slightest diffi- 
culty. I have sometimes substituted any common 
bands, when the proper cords failed me ; I have 
nailed these to the board when I have had no in- 
strument to bore the ordinary holes ; I have em- 
ployed nails for screws, and to form the directing 
bands, tow, wool, or rags ; these last materials, as 
also bran, sawdust, moss, and even soft hay, have 
served me in constructing my cushions for the boards ; 
the bark of a tree, moistened leather, the binding of 
an old book, have supplied the place of pasteboard ; 
and rope-ends, skin, or strong cloth, have not unfre- 
quently replaced the metallic hinges. 

" The double-boarded apparatus, it may be ob- 
served, will be found extremely useful in the case of 
fracture of the leg, with tendency to displacement, 
more especially when this occurs near the knee-joint, 
from the impossibility of applying the garter (jarre- 
tibre), one of the directing .bands of which, mention 
will be made farther on. 

" Although particularly applicable to fractures of 
the limbs, the suspension apparatus of M. Mayor 
may, under other circumstances, be of important 
use. It will readily be conceived how great might 
be its utility in any painful diseases seated upon one 
or other of the limbs, as well as in certain white- 
swellings, in arthritic and rheumatic tumefactions of 



184 MAYOR'S SYSTEM. 

the foot, or in any other serious affections of the 
knee, or of the articulation of the foot and leg. Its 
use might be extended to the treatment of transverse 
wounds of the thigh, or of the tendo-Achillis, for 
which the most perfect immobility is indispensable. 
There cannot be a better means, so long as the im- 
mobility of the fractured part is insured, of allowing 
the patient to vary his position in bed. 

, ADAPTATION. 

" It is not sufficient, although assertions of this 
kind have constantly been made, to place a fractured 
limb, after its reduction, upon an immoveable plane, 
in order to effect the cure. If this were true, for 
very simple cases, which would be but exceptions, if, 
for instance, in the majority of cases of simple frac- 
ture of the femur, a convenient position and a reten- 
tive bandage might be made to replace all those com- 
plicated machines which do more honour to the me- 
chanical knowledge of their inventors than to their 
knowledge of physiology ; it is not the less certain 
that other means are required also, to maintain the 
fractured extremities of a bone in perfect contact, to 
overcome the involuntary as well as the spasmodic 
contractile efforts of the muscles, and the indocility 
of the patient. But between these indications, and 
the necessity of violently extending in contrary ways 
the two extremities of a limb by mechanical powers 
which resemble only the rack of the inquisition, there 
is as wide a distance as between the glossocome of 
the ancients and the simple pillows of Sir Astley 
Cooper ; the surgeon who does not dare to expose 
himself to the dangers of the first, or to the insuffi- 
ciency of the second, has recourse in cases to the ex- 
tension apparatus of Dessault and others, which are 
not, however, free from inconvenience, but more often 
to the simple directing bands of M. Mayor, to which 
the only real objection that can be made is, that they 
are sometimes insufficient. 



MAYOR'S SYSTEM. 



185 



" In the greater number of cases of fractured limbs, 
the fragments face each other; whence the necessity 
of exerting pressure in the direction of their diameter, 
if the displacement exist in relation only to the axis 
of the body of the bone, or of pulling at the same 
time at the lower fragment, if the displacement is 
longitudinal, or in other words, if the broken ends 
overlap, in order to effect their coaptation. The 
hands alone of the surgeon and assistant are sufficient 
to fulfil effectually these indications ; but as they are 
only temporary means, recourse must be had, in order 

Fig. 133.] 




to render the effects permanent during the whole 
time necessary to the consolidation, to the aid of an 
lb* 



186 



MAYOR'S SYSTEM. 



intelligent machine, if such an expression may be 
used, which, in accomplishing this end, will in no 
respect inconvenience the patient. 

" Let the fracture of a leg be taken as an instance ; 
if it be of such a nature as not to exact the continued 
extension of the limb, and position alone suffices to 
maintain the broken ends in apposition, the surgeon 
has only to confine himself to the application, below 
the knee, of a tie or garter, the central portion of 
which has merely to be applied upon the anterior, or 

Fig. 134. 




one of the lateral faces of the limb, and its ends 
attached either separately on each side, or together, 
on the outside or inside of the board, Fig. 134. The 



MAYOR'S SYSTEM. 187 

object here in view, as will be easily perceived, is to 
fix the limb upon the board and give a due direction 
to the superior osseous fragment. The garter, like 
all the other directing bands, may be made of a bit 
of common roller, or a longitudinal compress ; but 
M. Mayor prefers those he ordinarily employs. These 
directing bands, the form of which may be seen in 
the figure, should be thick and soft, in order to pre- 
serve their shape, and prevent them from exercising 
a painful pressure. They should be constructed of 
two pieces of linen cloth, from three to five inches 
wide at the middle, with a layer of wadding, char- 
pie, tow, or wool, interposed between them; to the 
two extremities of these bands should be sewed tapes 
of convenient dimensions, or padded handkerchiefs 
will do as well. The figure indicates so clearly the 
manner of disposing them that it is unnecessary to 
dwell upon them longer here: the place, however, 
they are to occupy upon the limb will be spoken of 
by-and-by. 

" When these simple bands are found insufficient 
to fix the limb solidly upon the board, or when it is 
necessary, in order to maintain the fracture reduced, 
to exert continued traction on the limb, the following 
pieces must be added : To the inferior extremity of 
the board above spoken of, a foot-support is to be 
adapted, of the shape of a ladder, as in Figure 130, 
by means of mortises, a a, pierced in the former to 
receive it ; it should be from eight to ten inches high, 
and form with the board an angle of about eighty 
degrees. 

" The object of this foot-board is to fix the heel- 
strap or ordinary gaiter, which, on one hand, embraces 
accurately the instep, heel, and malleoli, and on the 
other, is attached by means of the two tapes, which 
terminate it, to one of the sides of the ladder, ac- 
cording to the direction desired to be given to the 
limb. 



188 MAYOR'S SYSTEM. 

" Thus, by means of the gaiter on one hand, and 
the foot-frame and heel-strap on the other, the elon- 
gation of the limb may be produced, and the overlap- 
ping of the fractured ends effectually prevented. The 
extension being made, is maintained by the heel- 
strap, and the counter-extension by the garter, or band 
at the knee, without taking into account the weight 
of the body, and the fixture of the limb upon the 
apparatus ; while the heel-strap, by fixing the foot, 
prevents rotation, inwards or outwards, of the lower 
fragment. 

" But thisalone is not sufficient to restore the limb 
to its natural form when the fragments are displaced 
in respect to the diameter of the bone ; and although 
the shortening of the bone has been provided against, 
nothing has yet been done to maintain the fractured 
ends in apposition. The following is the manner in 
which this indication is to be fulfilled; instead of ro- 
sorting, as is generally the case, to the uniform pres- 
sure exerted by the eighteen-tailed bandage, or that 
of Scultetus, with splints applied upon the soft parts 
that surround the ends of the bone, M. Mayor has 
recommended a means much more simple and more 
efficacious, and one which offers, besides, the advan- 
tage of not covering in with the apparatus the part 
of the limb at which the fracture is seated ; permits 
the surgeon also to visit it as often as he pleases, 
without the help of an assistant ; and to remedy the 
displacement, if any such should have occurred, as 
well as to dress the wound, should one exist, without 
meddling with the apparatus. The means in question 
consists in placing upon the part of the limb toward 
which the end of the bone is directed, and where it 
makes projection, the centre of a directing band, as 
Fig 133 (B); and fastening the extremities to the 
opposite side of the board; care being taken, how- 
ever, to see that the fracture is properly reduced. 
Two bands, which act in opposite directions, are occa- 



MAYOR'S SYSTEM. 189 

sionallj necessary, but more frequently the desired 
effect is obtained by one alone. The middle of the 
band should be applied upon the most convex part 
of the deformed limb ; one of its extremities is to be 
passed immediately under it, the other over, and both 
drawn with sufficient force and fastened to a peg 
inserted at the side of the board, which corresponds 
to the concavity of the limb, or in default of this, to 
a mortise pierced about this spot ; they may be even 
nailed at once to the board. 

" The directing bands should not be placed until 
the heel-strap and garter are adapted, the latter being 
fixed to the board upon the opposite side to that to- 
ward which the neighbouring band 
is to be directed ; without attending Fi 9- 135 « 

to this, the two extremities of the 
limb would be found to yield to the 
inverse tractions of the bands. The 
disposition of these several pieces 
is seen in the Figures 133, 134. In 
comminuted fractures with extreme 
tendency to displacement, a piece of 
pasteboard should be applied upon 
the anterior part of the limb, as in 
Fig. 135, the notched end being in- 
tended to touch the front of the foot. 

"To fix the femoral board more solidly the sur- 
geon should apply the large quilted band, or padded 
handkerchief before spoken of. This band should 
be of sufficient length to pass as a belt round the 
body, and terminate by a strap, to be attached to a 
strap and buckle fixed to the external and superior 
part of the board. This band serves at once as a 
body-bandage and perineal strap ; it passes first of 
all upon the groin of the injured side, then round the 
corresponding ilium and along the back, and is re- 
turned over the pubes to the upper part of the frac- 
tured thigh, where the buckle, fixed to the outer side 




190 MAYOR'S SYSTEM. 

of the board, receives it, or where, when this is 
wanting, it maybe fastened to some other convenient 
point of attachment. This belt, which, as may be 
perceived, tends to fix securely the femoral board 
upon the pelvis, is employed with the notched por- 
tion of the board, against which the tuberosity of the 
ischium rests, to produce the counter-extension, or, 
in other words, the resistance necessary to meet the 
tractions of the heel-strap ; while the latter acts at 
the same time upon the limb, which it elongates, and 
upon the board which it pushes upward, first beneath 
the ham and then upon the ischiatic tuberosity. 
Lastly, it is this portion of the apparatus which per- 
forms the greatest part in the effort ; but as it is aided 
firstly by the weight of the limb, which, placed upon 
an inclined plane, tends to descend ; and secondly, 
by the effort itself, which tends to elevate the bend 
of the knee, there can be no reasonable apprehension 
of the formation of sloughs or excoriations, such as 
the ordinary machines for continued extension too 
frequently produce. 

" This apparatus appears to unite all the qualities 
necessary for the reduction and consolidation of frac- 
tures of the neck of the femur. 

" To resume ; when it is required to maintain a 
reduced fracture of the femur, of whatever nature it 
may be, whether situated near the knee or in the 
shaft or neck of the bone, whether simple or compli- 
cated, with or without obliquity of the fragments, the 
thigh and leg are to be extended over the inclined 
plane, well cushioned, the belt applied round the 
thigh and pelvis, and the foot attached to the ladder 
or foot-board inserted in the lower end of the tibial 
board. A large quilted band, or several handker- 
chiefs, embrace the whole apparatus to confine the 
limb upon the board, when there is no deformity ; or 
the bands of direction, already described, made use 
of when the limb is curved, or there is any tendency 
to curvature. 



MAYOR'S SYSTEM. 191 

" With a view of raising patients in bed, when suf- 
fering from injuries to the lower extremities, M. Mayor 
proposes a Clinical Frame, which, from its simplicity, 
has many advantages over the complicated machinery 
of Earle, Jenks, &c, and may be advantageously 
used, especially by army surgeons, as it offers an ex- 
cellent bed, under even ordinary circumstances, being 
more steady, and not liable to the objections of an 
ordinary hammock. 

In speaking of it, he says : — " It is, doubtless, 
highly gratifying to have at our service, as practi- 
tioners, a number of easy and convenient kinds of 
apparatus, as well as appropriate and salutary thera- 
peutic agents ; but there are circumstances in which, 
if we have the latter at command, the former are by 
no means so much in our power ; whence it happens 
that we are occasionally called in, under circum- 
stances so perplexing, nay, so truly desperate, that 
we are content with positive inaction, rather than 
allow our interference to add to the patient's suf- 
ferings. 

" A large number of serious affections are daily met 
with which not only compel the patients to keep their 
bed, but even place them beyond the possibility of 
being removed from one part of the bed to the other, 
without their being subjected to the most excruciating 
pain, or even to actual danger. Whether they repose 
then upon a bed of eider-down, or are stretched upon 
a hard paillasse, these unfortunate individuals soon 
experience the want of having their bed better ar- 
ranged, and of being replaced in a position more sup- 
portable. They are excoriated at all those places 
where the bones project, as at the sacrum and the 
hips; the skin, deprived of its subjacent fatty tissue, 
constantly and powerfully pressed against the bones, 
soon becomes irritated, and ultimately sloughs; 
whence result those deep and extensive wounds, 
which, incessantly exposed to an invariable, and one 



192 MAYOR'S SYSTEM. 

might almost say corroding pressure, to the difficul- 
ties attendant upon their dressing, and, still worse, 
to the continual contact of urine and faecal matter, 
sometimes finish existence of themselves, or rapidly 
abridge its duration. 

"For the purpose of averting these serious incon- 
veniences various mechanical beds have been inven- 
ted, the most ingenious of which tend to elevat een- 
tirely, and with great gentleness, the unfortunate 
sufferers whom it would be impossible to move with 
the hands or any other means without occasioning 
the most heart-rending cries. 

" It will be readily conceived that the hands of 
one, two, or even three persons, are wholly insuffi- 
cient to support the entire body of an adult ; that the 
parts which are not sustained must be put upon the 
stretch, while the others are pushed up, and that, 
from this unequal manner of action, the most excru- 
ciating pains ensue. And let it be, moreover, re- 
marked, that the fingers do injury from their hard- 
ness ; while, in addition to all this carrying to and 
fro of the body of the sufferer, the most disagreeable 
shocks are constantly occasioned, which infinitely 
augment his already intolerable pain. In point of 
fact, patients in general prefer supporting the whole 
of the serious inconveniences allied to their actually 
invariable and painful position, rather than expose 
themselves, by this lifting about, to absolute tor- 
tures ; more especially when this has to be effected 
frequently. 

"Circumstances so melancholy have necessarily 
had the effect of awakening the solicitude of prac- 
tioners, the industry of patients themselves, and the 
compassion of those who are about them to contri- 
bute, if possible, to the palliation of such tortures, 
or at least to attenuate some of their more fatal 
consequences. But it has been more particularly in 
favour of the minority, that is to say, of the opulent, 



MAYOR'S SYSTEM. 193 

that such efforts have been crowned with success ; 
the lower orders of society still remaining without 
the pale of benefits arising from the invention of ma- 
chines calculated to be of avail in circumstances such 
as those just pointed out. The reason of this is 
evident ; the means indicated, and known under the 
title of Mechanical Beds, are so complicated and so 
costly, that they can only be within reach of persons 
in easy circumstances ; and even in hospitals these 
beds are generally few in number, and their use very 
limited. 

"So great, therefore, is the difficulty of obtaining 
these different kinds of apparatus, and still more the 
difficulty of adapting them to the exigencies of the 
most numerous classes of the community — classes 
which, be it observed, are the most constantly ex- 
posed to affections demanding contrivances of this 
kind — that it has been of the utmost consequence to 
consider other means than such pieces of mechanism 
present, and to seek for what seems to have been, 
hitherto, wholly lost sight of, namely, a contrivance 
within the reach of every individual, and applicable 
in every circumstance. This desideratum, M. Mayor 
thinks, will be found in his Clinical Frame, which 
be thus describes : 

" The first things to be sought for are two narrow 
boards or poles about the length of the patient, and 
two cross-bars of the same nature, of about a yard 
only in length. With these four pieces of wood, 
which may be easily united at their extremities by 
means of nails, rivets, bits of cord or handkerchiefs, 
we shall be immediately in possession of a frame in 
all respects stout enough for the end in view. It 
now remains to fill up the intermediate space ; and 
recourse must here be had to bands of webbing ; but 
if these should not be at hand, or at all events, should 
they be difficult to obtain, a few stout cravats would 
conveniently supply their place. Whether, then, the 



194 



MAYOR'S SYSTEM. 



webbing bands or the cravats be employed, they must 
be arranged crosswise, fastened securely at their ex- 
tremities to the sides of the frame, and, above all 
things, possess sufficient strength to resist the weight 
of the patient when suspended in the air. Substi- 
tutes for the above materials may be equally found 
in towels, napkins, sheets, or indeed in anything 
that would serve to constitute a bottom, soft, but yet 
sufficiently strong. After such simple data, it would 
be superfluous to point out how ingenious mechanics 
might modify the contrivance so as to prepare a frame 
more elegant, more in harmony with their own tal- 
ent, their desire of gaining reputation, or indeed 
with the fortune of those who employ them ; on the 
contrary, it would be advisable to urge the necessity 
of preserving the same simplicity in the construction 
of this, which will be found in the means destined to 
effect its elevation ; for there will be quite enough of 

Fig. 136. 




those who are ever on the alert to throw a species of 
luxury about a machine, who will believe that they 



MAYOR'S SYSTEM. 195 

have perfected this, when, from a simple and effec- 
tive instrument they will have converted it into a 
complicated one, despoiled of its best qualities. 

" To raise the frame, as well as the patient, who is 
supposed to be stretched upon its bottom, it would 
be sometimes sufficient to employ two or three dex- 
terous persons, such as are met with in hospitals; 
but in addition to the difficulty of finding such assist- 
ants, there will be always more or less inconvenience 
attending this operation when effected by the hands, 
in consequence of the shocks to which the frame will 
be constantly subjected from the slightest deviation 
from a simultaneousness of action. It will, there- 
fore, be found more convenient to have recourse to 
the means employed in the hyponarthecic suspension, 
and to apply to the whole body that which so well 
succeeds when applied to a limb. 

" Thus, the four angles should be perforated with 
four holes, as in the Fig. 136, through which a 
strong cord will be run in order to form two kinds 
of parallel bows or arc-loops of suspension ; the one 
longitudinal, the other transverse ; the former cor- 
responding to the sides, the latter to the extremities 
of the frame. 

" Recourse may also be had to one loop only, which 
will give to the frame the kind of tilting (jeu de bas- 
cule) observed in the beam of a scale. Movements 
of this kind are occasionally of importance, as when 
it is desired to raise the upper part of the body much 
above the horizon, or even the lower part alone. 

" One strong vertical cord, firmly attached, and 
passing through a pulley, will suffice for the eleva- 
tion of the frame charged with the patient, and must 
be arranged in the same manner as for the hypo- 
narthecia of the extremities. Thus, in the dwellings 
of the poor, the ceiling is usually provided with large 
beams ; nothing, therefore, will be found more easy 
than to arrange properly the staples or pulleys. 



196 MAYOR'S SYSTEM. 

Recourse may be equally had to a suspension bar of 
the kind represented in the figure and placed at the 
head of the bed. But when these resources fail, or 
cannot be employed without some disadvantage, let 
that be remembered which is done by certain me- 
chanics, particularly masons, when they desire to lift 
a heavy weight. The tripod, called generally the 
triangle, is the most easily constructed, the most 
firm, and in all respects the most convenient that can 
be employed for the object here proposed. This tri- 
pod, seen in the figure, should have a pulley attached 
to the iron hook observed at its upper part or point 
of union, in order to receive the vertical cord des- 
tined to raise the frame ; and thus provided, should 
be stretched across the bed. 

" In order to render the ascent of the frame per- 
fectly gradual and easy, the vertical cord should be 
made to pass round a cylinder fixed to two of the 
legs at their upper part, which may be turned either 
by a winch, or, if provided with holes and a small 
handle, as a capstan. Instead of this, if the free 
end of the vertical cord, after having passed through 
the pulley be firmly secured to one of the legs of 
the tripod, the above effect may be accomplished by 
means of a strong stick, which is employed to twist 
the cord, and which, by shortening it at each turn, 
elevates the frame. 

"But a still easier method is to employ a simple 
lever of the first power, — a pole, for instance, — 
whose fulcrum should be beside the bed, and to one 
end of which should be fastened the arc-loops them- 
selves, as seen in the figure, or, what is still better, 
the vertical loop, which will permit, during its eleva- 
tion, the frame to be better balanced ; in lowering, 
therefore, the other end of the lever, the ascent of 
the frame may be regulated with precision. The ful- 
crum, thus placed between the power and resistance, 
may be simply a rope's end made into a loop, and 



MAYOR'S SYSTEM. 197 

either firmly attached to the ceiling, or else to the 
tripod, which, in this case, instead of being stretched 
over the bed, should be placed beside it. 

" With the ordinary hyponarthecic loops attached 
to the Clinical Frame, which will allow of the point 
being varied where they are taken up by the verti- 
cal loop, we obtain, with the greatest facility, the 
power of elevating this frame in any direction we 
may choose, whether completely horizontal or with 
an inclination towards either of its extremities or 
either of its borders : an advantage which will not 
be without its utility on particular occasions. 

" It will be hardly necessary to observe that, in 
order to obtain these effects, it suffices merely to 
place the vertical cord at the centre of gravity itself 
of the frame, or more or less beyond this, in the 
direction either of the head or feet, and to make, for 
producing lateral inclination, the arc-loop shorter on 
one side than on the other. The arc-loops, however, 
ought to be collateral, for all these little advantages 
would be far less easily obtained were the cords, 
which perform the office of loops, placed transversely 
at either of the extremities of the frame. 

" Like all frames destined for a clinical use that 
just described may rest continually in place, in 
order that it may be raised at the moment desired, 
without previous preparation ; that is to say, the pa- 
tient should repose upon the bottom of the frame 
itself; or else this elevation may be applied only at 
the instant when occasion may require it. In the 
first case, we should be careful that the bands or the 
pieces of cloth which constitute the bottom of the 
frame do not annoy the sufferer, and are preserved 
as clean as possible. This will not be difficult if 
preference be given to large pieces of stout cloth, 
which will occasion so much the less inconvenience, 
as they may be stretched at will, without forming any 
incommodious folds. 
17* 



198 MAYOR'S SYSTEM. 

" It will be clearly seen, moreover, that with this 
disposition the surgeon may readily expose the ulcer- 
ation, and manage the application of dressings, by 
displacing from the bottom of the frame that portion 
which otherwise masks the affected parts. 

"When, on the other hand, it is found advisable to 
apply and elevate the frame several times, recourse 
should be had to the webbing bands, which, by means 
of a broad, thin, pliant piece of wood, may be glided, 
at the very moment, under the patient, much in the 
same manner as we should change the bandelettes in 
the apparatus of Scultetus. These bands, already 
attached to one side of the frame by one of their ex- 
tremities, are then brought to the opposite side, 
where they are fastened, by means of their free ex- 
tremities, through the intermedium of ribbands, but- 
tons, or buckles. This simple and easy means of 
gliding the bands under the patient, without at all 
incommoding him, and thus interposing between the 
bed-clothes and himself some sort of bottom proper 
to sustain him when elevated, would naturally sug- 
gest a still more simple support, namely, cravats or 
oblongs, of whatever tissue they may be composed, 
or of whatever breadth it may be thought proper to 
afford them. The Clinical Frame may not only be 
regarded as a species of hyponarthecia, destined to 
sustain momentarily the entire body in any manner, 
or in any direction desired to be imparted, but, being 
moveable, it will be seen to offer one very precious 
resource in a circumstance of the most important 
nature. Illusion is here made to the frightful slough- 
ing sores common to the lower and back part of the 
body, and which the pressure against the bandelettes 
renders insupportable, and tends constantly to exas- 
perate. Many are the means, without doubt, em- 
ployed to attenuate this horrible pressure ; yet they 
not only most often fail, but are difficult to procure, 
to maintain in place, and preserve in a proper state 



MAYOR'S SYSTEM. 199 

of cleanliness. The Clinical Frame, then, with very- 
little additional trouble, averts this inconvenience in 
the following manner: 

" Let the individual be extended over the bands 
placed transversely behind his back, and let us sup- 
pose that these bands are properly stretched from one 
side of the frame to the other ; it is clear that the poor 
sufferer will press upon them all with his entire weight. 
But if we detach those bands which correspond to the 
ulcerations, and if, at the same time, we remove suffi- 
cient of the hair, wool, or straw of the mattress which 
exists under the bands we have just placed aside, we 
shall immediately obtain a sort of hollow or depres- 
sion, in which the ulcerated surface will be but very 
slightly touched. It will be even possible to afford 
such depth and extent to this depression that the 
affected parts remain, as it were, in the air, in a com- 
plete state of isolation. In short, the bands placed 
above and below the seat of ulceration will sustain 
the body with great exactness, and will leave the 
sore open, and at that degree of elevation which may 
be judged necessary to substract it more or less from 
the pernicious influence of the pressure we are striv- 
ing to avoid. 

" It may be, however, observed, that instead of the 
excavation already spoken of, the mattress may be 
cut across, and of one mattress two smaller ones 
formed, which may be placed so as to allow of a suf- 
ficient space between them to guarantee the wound 
from pressure, according to its extent. 

" The Clinical Frame may, in campaign, admirably 
serve for a litter, or for the transport of the sick or 
wounded, as it possesses the advantage of the most 
simple form of construction, and of being made of 
materials to be found on all occasions. In this case, 
instead of webbing or other bands to form the bottom 
of the frame, recourse may be had to simple cords 
covered with hay, straw, leaves, grass, pieces of cloth- 



200 MAYOR'S SYSTEM. 

ing, &c. When it is found necessary to have the litter 
stationary, nothing would be more easy than to adapt 
to it a tripod or triangle, which would possess two 
remarkable advantages ; firstly, in forming solid feet 
for the support of such temporary bed ; and, secondly, 
in forming a frame proper to receive a blanket, or 
something of the kind, to serve for the purpose of a 
curtain, and to protect the sufferer from the sun, rain, 
wind, &c. 

"Many other occasions might, doubtless, be found 
for the use of this frame when put into suspension. 
Serving as a sort of hammock, it would seem to in- 
vite officers to establish it under their tents, and 
would guarantee them from the humidity of the 
ground, from insects, and other annoyances insepar- 
able from a bed placed directly upon the earth. The 
same may be said of it in a bivouac, where the tri- 
angle need only be covered by a cloak. 

" The suspension-bar, as seen in Fig. 136, adapted 
to a common hospital-bed, has been already pointed 
out as a means of establishing the suspension of a 
hyponarthecic apparatus : it requires no description, 
for the drawing will suffice to give the most correct 
idea of its construction. It will be seen therein to 
represent, however, only one-half of it, as the draw- 
ing of the other half would have interfered with the 
view of the tripod." 



PART THIRD. 



CHAPTER I. 

OF THE APPARATUS FOR THE TREATMENT OF 
FRACTURES. 

GENERAL CONSIDERATIONS. 

The responsibility involved in the proper treatment 
of this numerous class of injuries, renders them one 
of the most important parts of the practitioner's duty, 
because not to be able to set a broken limb, or reduce 
a dislocated bone, is enough to destroy all profes- 
sional reputation ; the public in general not being 
able, or willing, to understand the distinction drawn 
between the duties of the surgeon and those of the 
physician. Indeed, when a case turns out badly even 
in the hands of a most able surgeon, the friends of 
the patient, to use the language of Mr. Amesbury, 
"sometimes think they can never injure his reputa- 
tion sufficiently; and though in many instances he 
is not at all deserving of blame, they usually load 
him with epithets of ignorance, neglect, and pre- 
sumption. If we examine a little into this feeling 
we shall find that it is nothing more than what is 
naturally to be expected. Patients, as a general rule, 
know nothing scientifically of the nature of fractures, 
or of the means required for their cure ; consequently 
they judge of a surgeon's ability only by the result 
of his case. If it terminates well, he has only done 



202 



TREATMENT OF FRACTURES. 



his duty ; but if the limb be deformed, the patient 
will immediately say that the fracture was badly 
set, and be confirmed in this opinion not only by the 
observation of his friends, who seldom fail to find out 
cases to substantiate their belief," but also by every 
empiric who may be interested in the professional 
destruction of his attendant. Yet important as 
these injuries undoubtedly are, it would be foreign 
to a work of this kind to treat them in all their bear- 
ings, or consider the causes, physiological and patho- 
logical changes, &c, which a less condensed treatise 
might properly demand. 

I shall, therefore, in the consideration of this part 
of the subject, confine myself mainly 
Fig. 137. to such points as are most connected 

with the treatment; only hinting 
briefly at such general considera- 
tions (especially as respects the 
causes of the deformity, and the in- 
dication to be fulfilled in the treat- 
ment), as are concerned in the plans 
of practice; referring those who 
wish a more minute knowledge, of 
them, to the many articles to be found 
in all works on Surgery. 

The Bones being intended for the 
support of various portions of the 
body, and acted on by the muscles, 
it follows that any solution of con- 
tinuity in their structure, must in- 
volve very materially the use of the 
part, and create deformity from irre- 
gular muscular action. The over- 
coming of this deformity, and the 
retention of the broken ends in 
such a position as will be most 
favourable to their union, are then 
the first principles involved in the treatment of 



TREATMENT OF FRACTURES. 203 

fractures. To prove this, a slight reference must be 
made to the bond of union or Callus. The first eifect 
of fracture being a division of the fibres of the bone, 
with more or less laceration of the soft parts, inflam- 
mation necessarily follows. This results in fortunate 
cases, in the effusion and organization of lymph ; this 
subsequently becomes bone, and by its extension 
beyond the fractured extremities binds them to- 
gether externally (Fig. 137), until it is also effused 
within their extremities. This external matter, or 
Provisional Callus, being that which is first formed, 
is of course most directly implicated in the re- 
sults of the means employed, the second, or defini- 
tive callus, not being completed till long after the 
ordinary duration of the treatment. Certain circum- 
stances, as rest, position, and the prevention of too 
high a degree of inflammation, or the excitement of 
the necessary action where it does not naturally 
exist, are, therefore, essential to the cure, and the 
creation of these circumstances, or the fulfilment of 
these conditions, constitute the general principles of 
the treatment. But as the proper fulfilment and 
comprehension of these points can only be gained 
from an accurate knowledge of physiology, I can 
do little else, at present, than specify the general ob- 
jects to be attained by pursuing them. 

To accomplish the indications generally required 
for the cure of a fracture we must, therefore, 1st. 
Reduce the displaced ends of the bone ; 2d. Coap- 
tate and keep them reduced; and 3d. Subdue the 
local inflammation, and combat the accidents that 
may arise from the means of treatment. 

1st. Reduction. — The first indication, or the re- 
duction of the displaced ends of the bone, is limited 
to such fractures as are accompanied by this de- 
formity; such as those of long bones surrounded by 
powerful muscles, or exposed to blows, which can act 
directly on either fragment. 



204 TREATMENT OF FRACTURES. 

To accomplish the reduction resort is had to what 
is technically known as Extension, and Counter-Ex- 
tension, or the use of such means as tend to bring the 
bone to its original length. Extension is the force 
applied to that extremity of a broken bone which is 
furthest from the heart; and Counter-Extension that 
which exactly balances the extension, or prevents the 
whole body yielding to the force applied to the lower 
end of the limb. But in some instances, even in 
fractures of the extremities, as in fractured patella, 
olecranon, &c, it is improper, if not impossible, thus 
to make extension and counter-extension, and we are 
obliged to resort to position, or placing the muscles 
in a state of relaxation, in order to accomplish our 
object. This latter point, position, has for many 
years been a disputed question among surgeons ; Pott, 
and many of the English school, contending for its 
advantages, whilst the French and American writers 
advocate the more mechanical means of treatment, 
averring that position alone would prove injurious to 
most cases. As in most disputes, opinions have 
been urged to the injury of all parties. That 
in many cases extension is absolutely necessary 
to the reduction of a fracture cannot be doubted, 
but that position is also not to be neglected is equally 
indisputable. Take, for example, a fractured clavicle, 
the mere extension effected by carrying the shoulder 
outwards would not relieve the deformity without at- 
tention being also paid to the position of the shoulder, 
viz., backwards and upwards. Again, a fracture of 
the femur, or of the leg, would not be properly re- 
duced by mere extension and counter-extension, un- 
less at the same time the position of the foot was 
attended to. The prudent practitioner will there- 
fore bear in mind simply the fact, that it is the force 
of muscular contraction that is to be overcome ; and 
whether accomplished in an extended or flexed posi- 
tion, by compression of bandages, or without them, 



TREATMENT OF FRACTURES. 205 

not rest satisfied until he has accomplished this ob- 
ject. In fractures of the long bones the weight of 
French and American authority is in favour of the 
extended position of the limb ; whilst the pupils of 
Pott, and many of the English surgeons, still prefer 
the flexed, especially in the treatment of fractures 
of the lower extremities. 

2d. Coaptation, and keeping the hones reduced. — 
The accomplishment of these indications is usually 
the result of the employment of a certain force more 
or less directly to the seat of fracture. Where two 
bones are parallel and it is important to keep them 
at a certain distance, as in the bones of the forearm 
and leg, or where one fragment is liable to such irre- 
gularity of position as cannot be otherwise overcome, 
it becomes necessary for the surgeon to press upon 
them with his fingers, and mould them to the desired 
condition ; thus coaptating or setting the fracture. 
But where the deformity can be remedied by the 
action of muscles it is better not to finger the seat 
of fracture, as the pressure of the soft parts on the 
sharp points of bone might create such irritation as 
would rather increase than relieve the existing symp- 
toms. 

As the muscles are, also, the motive powers of the 
body, and as they are attached to the bone, it fol- 
lows, that even after the setting of a bone, any sud- 
den action on their part must tend to displace the 
fracture ; so that the common idea of a bone once set 
being always afterwards in its proper position, is in- 
correct, the facts being most frequently the reverse, 
and the attention of the surgeon to the state of the 
bone being always required at each dressing, until 
consolidation has taken place, lest the action of the 
muscles again displace it. In order to guard against 
such changes various means are employed, as Splints, 
Cushions, or Junk-bags, Pads, Extending and Counter- 
18 



206 TREATMENT OF FRACTURES. 

Extending Bands, Pallettes, or Hands Splints, Soles 
or Foot Splints, Compresses, Pads, Slings, and 
Rollers, — the minute directions for the preparation 
and application of each of which will be given in con- 
nection with the treatment of the particular fractures 
for which they are required. 

3d. Combatting inflammation, and the accidents 
resulting from the means of treatment. — These, 
though placed last, are by no means the least import- 
ant items in the treatment, fractures being so gene- 
rally the result of violence that inflammation is very 
apt to ensue. This, provided it does not run too 
high, or involve neighbouring parts, need not be in- 
terfered with, a certain amount being necessary, as 
stated, to the formation of callus. But should the 
inflammatory action become excessive, the use of cold 
washes, and the antiphlogistic system generally, will 
be necessary to prevent its going too far. As a gene- 
ral rule, such a degree of inflammation should exist 
about a fractured bone as will result in the effusion 
of lymph. Beyond this, the effect is injurious to a 
rapid cure. 

The combatting of the accidents resulting from 
the plan of treatment will more frequently test the 
surgeon's skill than any other portion of the case. 
Excoriations, ulcerations, bed-sores, and constitu- 
tional symptoms, such as fever, diarrhoea, &c, are 
all liable to complicate a case ; and there are few of 
any experience who have not felt the evils to which 
I now refer. Every attention must, therefore, be 
given to the proper construction of the bed and of 
the apparatus ; to the room in which the patient is to 
be confined; to diet, &c, &c, in order to guard 
against accidents, which sometimes will produce a 
result that nothing but previous experience could 
have led any one to anticipate. In the plan of Pott, 
or the flexed position of the lower extremity, there 



TREATMENT OF PRACTURES. 207 

may be sloughing and bed-sores ; in the extended 
state of the limb, ulceration on both heel and peri- 
neum; whilst paralysis, arrest of circulation, and 
excoriation, may follow the treatment of similar in- 
juries in the upper limbs. As, however, these evils 
can only be hinted at here, or better refered to in 
each accident, I shall, without further delay, pass 
to the treatment of particular fractures. 



CHAPTER II. 

OF FRACTURES OF THE BONES OF THE HEAD AND 
TRUNK. 

FRACTURES OF THE SKULL. 

The treatment of fractures of the skull being de- 
pendent on whether or not it is necessary to tre- 
phine, their particular consideration would here be 
out of place. I merely, therefore, state, that in any 
case where it is necessary to retain dressings to the 
cranium, reference should be made to the Recurrent 
Bandage of the Head; the Single or Double T; the 
Handkerchiefs of Mayor ; the Bandage of Gralen, 
or to the Sling of Four Tails, as before given. 

FRACTURE OF THE BONES OF THE NOSE. 

It not unfrequently happens that in consequence 
of the violence necessary to produce this fracture, 
the bones are driven in upon the nasal cavity, or de- 
pressed, so as to destroy their natural arched form. 
To remedy this, a probe or director should be intro- 
duced within the nostril, and the depressed bone 
raised to its proper level. Then, any dressings to 
the part, or to the internal angle of the eyes, that 
may be necessary to subdue the inflammation and 
prevent injury to the nasal duct, should be retained 
in position by the Double T bandage of the nose, 
Fig. 71, page 114. No means are required to 
keep the bones reduced after the fracture is set, as 
they are not liable to displacement from muscular 
action. 



FRACTURES OF THE BONES, ETC. 



209 




IN FRACTURES OF THE LOWER JAW, 

Anterior to its angle, we may 
employ Dr. Barton s Bandage, 
p. 86, with the use of a paste- 
board splint, made as in the fig- 
ure, like the body of a sling ; or 
we may use the Sling of the Chin, 
as before mentioned, or the Band- 
age ofProfessor Gibson, which is 
composed as follows : — 

GIBSON'S BANDAGE FOR FRACTURE OF THE JAW 

Consists of a roller five yards long and two inches 
wide, and of a compress and splint, when neces- 
sary. 

In its application, after having carefully examined 
the injured parts, and replaced any of the teeth that 
may have been deranged, run the fingers along the 
margin of the jaw, in order to mould it into its proper 
shape. Then closing the 
mouth firmly, make the Fig. 139. 

lower teeth press fairly 
upon the upper, and place 
a compress of moderate 
thickness under the frac- 
tured portion, where it 
should be held by an as- 
sistant. Next take the 
single-headed roller, and 
commencing on the top 
of the head, pass it by 
several turns down the 
side of the face, under the 
jaw, and over the compress ; after the third turn of 
this kind make a reverse on one temple, so as to 
run off perpendicularly and surround the forehead 
and occiput by circulars of the vault of the cranium. 
18* 




210 FRACTURES OF THE BONES 

On the third of these turns, pass from the occiput, 
obliquely over the back of the neck, and under the 
ear, to make three circulars of the chin and neck ; 
from the neck pass obliquely upwards, to go circu- 
larly round the forehead, and place pins at each turn. 
If the turns are likely to slip, fasten a small strip on 
the forehead, and carry it over the vertex to fasten 
it to the turns on the neck, and thus secure them 
more perfectly, as seen in Fig. 139. 

During the treatment of fracture of the jaw the 
patient must be fed on soft, semi-liquid food, and not 
allowed to speak ; but there is no occasion for in- 
serting a piece of cork between the teeth, or extract- 
ing any of them, as there is usually enough space 
between them as they stand, to enable any one to 
suck food into the mouth. This fracture, under 
favourable circumstances, consolidates in four or 
six weeks, but the patient should not be allowed to 
eat hard or tough articles for some weeks after- 
wards. 

FRACTURES OF THE VERTEBRA 

Kequire no apparatus. Attention must here be 
mainly directed to the use of the catheter and of 
enemata; directions for which will be given here- 
after. An important point to be recollected in these 
injuries is, not to turn the patient on his belly in 
order to examine the back, but to turn him only on 
to his side ; for as the abdominal and intercostal 
muscles may be paralysed by the injury, the dia- 
phragm alone can act in respiration. But in order 
that the diaphragm may descend, the abdomen must 
bulge out sufficiently to permit the descent of the 
bowels and expansion of the chest. If, then, the 
patient is kept for a length of time on his belly, 
there is not sufficient force in the diaphragm to do 
this, as it has to overcome the resistance made by 
the weight of the body on the bed, consequently, if 



OF THE HEAD AND TRUNK. 211 

the examination should be tedious, the patient will 
run the risk of being suffocated. 

IN FRACTURES OF THE STERNUM 

The indications are, to prevent deformity from the pro- 
jection, or depression of the fragments ; to keep the 
chest at rest, and oblige the patient to breathe by 
the diaphragm and abdominal muscles. These may 
be well fulfilled by placing a compress over the part, 
and constricting the chest by the Crossed Bandage, 
or by the Spiral of the Chest, as before shown, so as 
to prevent displacement in the respiratory move- 
ment. 

FRACTURES OF THE RIBS 

Are to be treated on the same principles as those of 
the sternum, the compresses being over the seat of 
fracture, if the fragments project externally ; but 
over the end of the ribs, if they point inwardly. 
These compresses and the whole chest are to be 
confined by the Spiral Bandage of the Chest (Fig. 41), 
which should be drawn very tight. 

FRACTURES OF THE PELVIS 

Require no other apparatus than a broad bandage 
of the abdomen and pelvis ; there being here little 
or no tendency to deformity, owing to the attach- 
ment of the muscles. 

FRACTURES OF THE CLAVICLE 

Are treated by several kinds of apparatus, all having 
for their object three indications, viz., the keeping 
of the shoulder upwards, outwards, and backwards. 
The objects to be attained by these movements are 
as follows : — 1st, the shoulder should be elevated in 
order to bring the fragments to the same level ; 2d, 
carried outwards to preserve the proper length of 
the clavicle, keep the arm at its proper distance from 
the sternum, and preserve the pectoral space ; 3d, 



212 



FRACTURES OF THE BONES 



backwards, to bring the bones into the proper line 
in front. The first means of fulfilling these import- 
ant indications are those recommended by the sur- 
geon who specially enforced them, and are known 
as the 

APPARATUS OF DESSAULT. 

This is composed of three single-headed rollers 
eight yards long and two and a half inches wide ; of 
a pad the length of the humerus, four inches thick at 

its base, made in the 
of 




a wedge by 
folding muslin on itself, 
so as to form a compress 
graduated from one end 
(as before shown), and 
then covered with a 
piece of muslin ; of a 
compress to go over the 
broken bone ; of a short 
sling to support the fore- 
arm ; and of a piece of muslin sufficiently long and 
wide to surround the chest, arm, and bandage, and 
keep the whole dressing in its place. 

These being prepared, the patient should be seated 
either on a bench, or chair without a back, or else stand- 
ing, an assistant elevating the arm of the injured side, 
and carrying it off at right angles to the body. The 
surgeon now places the pad in the axilla, the thick 
end upwards, where it is to be held by the assistant. 
The initial end of the first roller is then placed on 
the middle of the pad, and two or three circular 
turns of the chest made, in order to fix it, after 
which the roller should be carried up over the front 
of the thorax ; over the sound shoulder ; under this 
arm-pit to make a semi-circular turn on the front of 
the chest ; over the pad ; round on the back ; over 
the sound shoulder ; under the arm-pit, and then 
spirally around the chest (Fig. 141). 



OF THE HEAD AND TRUNK. 



213 



Fig. 141. 




Then flex the forearm on the arm, and bring the 
latter down along the pad, 
pressing its lower extrem- 
ity forcibly against the 
side of the chest. This, 
by forcing the shoulder 
outwards, draws the clavi- 
cle to its original length ; 
for the humerus being thus 
made a lever of the first 
kind, its upper end is 
drawn from the shoulder 
in proportion as the lower 
end is forced against the 
thorax. At the same time 
direct the head of the humerus upwards and back- 
wards, which immediately reduces the fracture, and 
the assistant should hold it so until the next two 
bandages are applied. 
These are intended to ■%• 142 - 

keep the fracture reduced. 
With this view, place the 
commencement of the se- 
cond roller in the axilla 
of the sound side ; carry 
it across the breast ; over 
the upper part of the arm 
of the injured side, and 
obliquely round the back, 
to the axilla, whence it 
started, and continue 
these turns down the 
arm to the upper part of the forearm ; drawing them 
gently at first, and gradually tightening them as 
they approach the elbow, so as to force it well into 
the side of the body (Fig. 142). 

The object of this roller is to carry the shoulder 
and head of the humerus outwards by pressing the 
elbow inwards. In order now to keep the shoulder 




214 



FRACTURES OF THE BONES 



upwards and backwards, the third roller should com- 
mence in the sound axilla, pass obliquely over the 
front of the chest to the fracture, where there 
should be a compress ; over this, and down the back 
of the arm to the elbow ; thence obliquely upwards 
to the front of the sound axilla; under this, ob- 
liquely upwards over 
■%• 143 - the back, over the 

fracture, down the 
front of the arm to 
the elbow, and thence 
obliquely to the back ; 
then to the sound ax- 
illa ; under this to its 
front part, and over 
the chest and frac- 
tured bone, to run the 
same course, and end 
by circulars of the 
chest, so as to fix 
the whole. The first 
turns form two trian- 
gles (Fig. 143), one of which is before the breast, 
the other on the back, and are the only difficult 
turns to recollect. But when it is remembered that 
starting from the sound axilla, the bandage is to go 
over the fracture, down the arm to the elbow, and 
from the elbow always to the axilla, there will be 
found no difficulty in its application. 

It now remains to support the forearm by a sling, 
and cover the whole apparatus by the piece of mus- 
lin before spoken of, in order to prevent the turns 
of the roller from slipping. 

The principles upon which this bandage acts, viz., 
by converting the humerus into a lever of the first 
kind, carrying its lower extremity forwards, inwards, 
and upwards, and thus pushing the shoulder back- 
wards, outwards, and upwards, renders it exceedingly 




OF THE HEAD AND TRUNK. 



215 



well adapted to these fractures. The pad placed 
in the axilla serves as the fulcrum, the arm acts as 
the lever, and the clavicle as the body to be moved. 
One of the great advantages claimed for this appa- 
ratus is, that it may be readily constructed. It is 
liable, however, to some objections ; thus, for in- 
stance, the compression which it exerts about the 
chest renders it ill adapted to females or patients 
of a delicate constitution ; it is also very heating in 
warm weather ; requires to be taken off and re-ap- 
plied very frequently in consequence of its becoming 
easily displaced by the movements of the patient, 
especially if restless ; whilst the pressure on the 
axillary nerves and bloodvessels, from the too great 
tightness of the second roller or the use of a pad 
which is rather full, often causes considerable pain 
and inconvenience. 



BOYER'S BANDAGE FOR THE SAME 

Is composed of a wedge-shaped pad for the axilla ; 
a quilted belt of web- 
bing or of linen, about Fig. 144. 
five inches wide to sur- 
round the trunk, and 
fasten by means of 
straps and buckles ; 
and a circular band for 
the arm, of the same 
materials as the belt, 
made to lace in front. 
Four straps are attach- 
ed, two on each side, 
near the uniting edges, 
and four buckles to cor- 
respond with these are 
fastened upon the belt, 
two before and two be- 
hind the arm. Then 
the pad being placed in the axilla and its bands car- 




216 



FRACTURES OF THE BONES 



ried one before and the other behind the chest to 
the opposite shoulder, are tied and the belt is then 
passed round the body, beneath the pad, and a little 
above the bend of the elbow, in order to buckle pos- 
teriorly. Next, the circular band is laced upon the 
arm, and brought in to the trunk by means of the 
straps and buckles. While the elbow is thus fixed 
firmly to the side, the pad tends by its resistance to 
push the superior part of the arm outwards, and the 
elbow may be moved either forwards or backwards by 
merely tightening the anterior or posterior straps, so 
as to carry the shoulder in the opposite directions. 

This bandage, acting upon the same principles as 
that of Dessault, is preferable to the latter only from 
the circumstances of its not being liable to become 
displaced, and from its causing a more limited com- 
pression of the chest ; the compression being capable 
of being regulated by means of the straps and buckles 
which unite the ends of the belt, better than by the 
turns of the roller. 



MAYOR'S HANDKERCHIEF BANDAGE FOR THE SAME 



Fig. 145. 



Requires two large handkerchiefs, one folded in tri- 
angle, the other in a broad 
cravat; a cushion for the 
axilla ; and a soft pad for 
the opposite shoulder. 
After preparing these, let 
the cushion be placed in the 
axilla, and the arm brought 
against it with the forearm 
bent. The doubled edge of 
the handkerchief, folded 
triangularly, is then to be 
made to envelop the elbow 
by folding its summit 
around, while the angles 
support the hand ; the pos- 
terior angle being carried up under the axilla and 




OF THE HEAD AND TRUNK. 217 

behind the back to the opposite shoulder, upon which 
a compress should be previously placed, after which 
the anterior angle should be brought up in front to 
meet the former and tie. 

The second handkerchief, in cravat, is to confine 
the elbow and forearm more securely to the body, 
by being carried round the waist, and fastened upon 
the opposite side of the trunk. 

Mayor modifies this bandage in the following man- 
ner when intended for fracture of the acromion : 
After the first handkerchief or sling is applied some 
compresses should be placed upon the injured 
shoulder, and a few vertical turns of a roller passed 
round the shoulder and elbow, as in the third roller 
of Dessault; after which, the second handkerchief is 
to be applied as above; the cushion under the axilla 
should also be omitted, and a compress substituted, 
before applying the first handkerchief, between the 
elbow and side. 

This mode of treating fracture of the clavicle an- 
swers very well as a provisional dressing, and better 
than the ordinary sling ; but where the other means 
can be obtained a more perfect cure will certainly 
be accomplished by them. 

FOX'S APPARATUS. 

In 1828, Dr. George Fox, of Philadelphia, then 
Resident Surgeon of the Pennsylvania Hospital, at 
the suggestion of his friend Dr. James A. Washing- 
ton, introduced into the practice of that institution 
an apparatus, for the treatment of fracture of the cla- 
vicle, that has since gained a large share of profes- 
sional confidence. Being slightly modified in accord- 
ance with the experience of the hospital, it, as at 
present used, consists of a stuffed collar ; a pad about 
five inches long, four wide, and two or three inches 
thick at the base ; and of an elbow piece or sling, as 
shown in Fig. 14(3. 
19 



218 



FRACTURES OF THE BONES 




The Collar is made of a piece of muslin four inches 

wide and long enough to 
Fig. 146. go around the shoulder, 

sewed together on its 
sides, stuffed with cot- 
ton, and then joined 
at its ends. The 
Pad is wedge-shaped, 
and like Dessault's, 
except in its size, 
being neither so thick 
nor so long, as it is 
merely intended to fill 
up the space between 
the upper part of the 
arm and the side of the 
body, and yet leave 
a space between the 
elbow and the ribs. Two tapes are to be attached 

to the thick end of the 
Fig. 147. pad, in order to fasten 

it to the collar. The 
Elbow-piece, or Sling, 
is made of strong mus- 
lin or brown holland, 
like half of the sleeve 
of a coat, so that it 
may embrace the el- 
bow, mount half way 
up the arm, and de- 
scend nearly to the 
wrist. To its upper and 
posterior ends are at- 
tached two pieces of 
broad tape, long enough 
to reach across the back to the collar ; and on its 
lower portion are two loops to receive a tape for the 
front fastening. In applying the apparatus place the 
collar on the sound shoulder ; the pad in the injured 




OF THE HEAD AND TRUNK. 



219 



axilla ; fix it there by carrying its tapes, one in front 
the other behind the chest, and tie them on the 
collar. Flex the forearm ; place the elbow-piece on 
it and the arm ; bring the arm against the pad by 
carrying the forearm across the chest, and tie the 
loops which are on the sling near the wrist to the 
front of the collar, as in Fig. 147, when the fracture 
will generally be found to be perfectly reduced. 

Should there, however, be any occasion to carry 
the shoulder more outwards, it may be accomplished 
by drawing the wrist nearer to the collar ; whilst if it 
is necessary to carry the shoulder more upwards, or 
backwards, draw upon the tapes which are attached 
to the upper and posterior part of the sling. Next 
fasten the tape which is attached to the upper 
and posterior end of the sling to the collar behind, 
carrying it across the back, so as to thrust the shoul- 
der upwards, and tieing that attached to the elbow 
also to the collar behind the back. The elbow will 
thus be forced into the 
side, and the shoulder Fig. 148. 

thrust outwards and 
backwards to any ex- 
tent that may be de- 
sired. Fig. 148 gives 
a view of the arrange- 
ment of the bands 
upon the back. The 
upper strap is at- 
tached to the pad; 
the second one to the 
superior posterior 
portion of the sling, 
and the third to its 
posterior inferior ex- 
tremity, or the point 
of the elbow. 

Observations. — Of all the means recommended for 




220 FRACTURES OF THE BONES 

the treatment of fracture of the clavicle few are 
more simple, or fulfil better the indications, than this 
apparatus of Dr. Fox. Made in a few minutes of 
materials nearly always at hand, reducing the frac- 
ture, yet leaving it open to inspection, light and easy 
of application, producing no constriction of the chest, 
pressure on the mammse, or on the axillary vessels 
or nerves, it offers advantages that other means do 
not generally possess, and its introduction into prac- 
tice has caused the perfect cure of many cases, 
and saved patients much unnecessary suffering and 
inconvenience. In the Pennsylvania Hospital it is 
the only means employed for the treatment of this 
injury, and the repeated testimony of the numerous 
cases treated in this large hospital, where such frac- 
tures are extremely numerous, has proved its ability 
to produce perfect cures. Indeed, so perfect are the 
cures, even in very oblique fractures of this bone, that 
it is a rare thing for a simple case of this fracture to 
go out of the house with any deformity, save that 
which time cures, viz., the deposition of the provi- 
sional callus. From 1829 up to the year 1838, a 
period of nine years, seventy-five cases of fractured 
clavicle were treated in the house ; of which sixty- 
three were discharged cured, and twelve left the house 
while under treatment, the apparatus allowing of their 
walking about as usual. 1 In the subsequent years, a 
large number of cases have been treated by other 
surgeons with such success that few who have em- 
ployed it ever resort to any other means of treat- 
ment, except in special cases, where an additional 
bandage, as a posterior 8, &c, may be added. But 
generally, when there is any derangement of the frac- 
ture, it is only necessary to tighten the anterior or 
posterior tapes of the sling, as above directed, in order 
to remedy it. The effect produced on a clavicle by 

1 Wallace's Statistics of Fracture : Med. Examiner for 1838. 



OF THE HEAD AND TRUNK. 221 

this apparatus is well shown by the testimony of Dr. 
Norris, one of the surgeons of the hospital, who, in 
his notes to Liston's Surgery says, "he was enabled 
to treat with entire success a forward dislocation of 
the sternal end of the clavicle, after Dessault's band- 
age had been several times well applied, but without 
success." The difficulty of retaining the bone in its 
position, in this injury, being so much more difficult 
than in cases of fracture, speaks highly in favour of 
the power of this simple bandage. 

FRACTURES OF THE SCAPULA 

Are generally accompanied by so much inflammation 
from the contusion, as to render its removal an ob- 
ject of greater importance than the treatment of the 
fracture itself. Warm fomentations by means of 
bags of chamomile flowers, or flannels wrung out of 
hot water, leeches, &c, must, therefore, first be em- 
employed ; after which we may employ the pad, and 
first and second roller of Dessault, Fox's Apparatus, 
or the bandage of Velpeau. The latter, which is here- 
after shown, is recommended by its distinguished 
author as especially applicable to acromio-clavicular 
luxations ; to fractures of the acromion or other points 
of the scapula ; to fractures of the neck of the humerus 
as well as to fractures of the clavicle. But from 
numerous opportunities that I have had of witnessing 
the result of its application to the latter injury, in 
his own wards, I think it is not so perfect in its 
cures as the means just referred to. To the other 
cases it is well adapted, and is applied as follows : 

VELPEAU'S BANDAGE. 

Make the patient embrace the sound shoulder with 

the hand of the injured side, placing a compress or 

piece of muslin between the side of the chest and the 

injured arm, in order to prevent excoriation of the 

19* 



222 



FRACTURES OF THE SCAPULA. 



two surfaces, from contact and perspiration. Then 
place the initial extremity of a roller ten yards long 

and two and a-half 
■%• 149 - inches wide, under, or 

behind the axilla of the 
sound side ; conduct it 
over the back ; over the 
injured clavicle; down 
on the front and outside 
of the arm ; under the 
outside of the elbow; up 
and over the chest to 
the sound axilla. Make 
two similar turns, and 
on again reaching the 
axilla pass circularly 
around the chest to the 
same axilla; then make 
a turn over the clavicle 
and arm ; then a circular, and so on until the band- 
age reaches the upper part of the forearm, as seen 
in Fig. 149. By means of this bandage, especially 
when wet with starch or dextrine, the arm can be 
supported in a firm cap, which will last for weeks 
without changing ; but where these articles are not 
used, several pins must be placed at the different 
turns in order to secure them. It will require but a 
single application of this bandage to prove its power 
in the accident referred to ; and as dislocations of the 
humeral extremity of the clavicle are generally ad- 
mitted to be retained with difficulty in their proper 
position, this bandage will be found to be a very 
valuable addition to the other means of treatment. 




CHAPTER III. 

OF FRACTURES OF THE UPPER EXTREMITY. 

FRACTURE OF THE NECK OF THE HUMERUS 

Is generally treated by Boyers Bandage, which is 
composed of two rollers two and a-half inches wide ; 
of three strong pasteboard splints between two and 
three inches broad, and the length of the arm ; of a 
pad four inches thick at one end, terminating at the 
other in a narrow point, and long enough to reach 
from the axilla to the elbow, and thus serve as an 
inside splint, and fulcrum for the reduction of the 
fracture ; the thick end being placed in the axilla, 
if the lower fragment is drawn inwards, but the re- 
verse, if the upper one is thus drawn ; lastly, a strip 
is necessary to support the forearm. 

Then, the fracture being reduced, and maintained 
by assistants, the surgeon fixes the initial extremity 
of one of the rollers at the upper part of the wrist 
by two or three circulars, and applies it to the limb, 
as in the Spiral of the Upper Extremity, until he 
arrives at the seat of fracture, where several turns 
must be made around the part so as to bind it firmly, 
and overcome the action of the muscles most likely 
to cause displacement. From hence the surgeon 
carries the head of the roller twice round the oppo- 
site axilla, and confides it to one of the assistants, 
who retains it upon the top of the shoulder of the 
injured side. The first splint being then placed in 
front, reaches from the bend of the arm, as high as 
the acromion ; the second, on the outside, from the 
external condyle to the same height ; and the third, 
from the olecranon behind, to the margin of the 
axilla. 



224 OF FRACTURES OF THE 

These being given to another assistant to hold, 
take the same roller, or a new one, and fasten the 
splints to the arm, by moderately-tight spiral turns, 
and while the assistants still keep up the extension, 
place the cushion between the arm and trunk, taking 
care to put that end upwards which the deformity 
calls for. Lastly, bring the arm against the trunk, 
and confine it there by means of the second roller, 
or turns of the same one applied horizontally around 
the body. Each turn of this roller should tighten 
from above downwards, if the lower fragment be dis- 
placed inwards ; but if it is drawn outwards, the 
turns should be slack below and tight above, in order 
to act on the extremities of the lever formed by the 
humerus. The forearm is then to be sustained by a 
sling, which should not go under the elbow, lest it 
cause shortening of the arm, but should merely sup- 
port the hand. 

FRACTURE OF THE BODY OF THE HUMERUS 

Is also most frequently treated by Boyer's Apparatus. 
This consists of a single-headed roller eight or nine 
yards long and two and a-half inches wide ; four 
splints, not quite so long as the arm, nor so broad as 
to touch each other when applied ; and some charpie 
or cotton to pad them. 

The surgeon then commences by applying a spiral 
bandage of the limb, fixing its initial end by a few 
circular turns above the wrist, and proceeding as in 
the spiral bandage of the upper extremity before re- 
ferred to. Continuing the turns of the roller from 
the elbow to the upper part of the limb, he should 
apply the bandage firmly over the seat of the frac- 
ture, filling up the depression about the insertion of 
the deltoid muscle, in order to render the pressure 
uniform. Next placing the splints, well padded, 
along the arm, on its inside, front, back, and outside, 
and resuming the roller, let him cover in the splints 



UPPER EXTREMITY. 225 

by spiral turns of the bandage, and fasten it by pins 
until the whole is rendered firm ; when the forearm 
should be fastened across the chest. 

If in both of these fractures this last point is over- 
looked, and the arm and forearm be not well secured to 
the body, such motion will be produced at the elbow- 
joint as will derange the lower fragment, while 
the slipping of the turns of the spiral bandage on the 
forearm will necessitate its almost daily re-applica- 
tion. 

THE PLAN OF THE PENNSYLVANIA HOSPITAL 

Obviates this, and is as follows : — After applying a 
roller from the fingers to the shoulder, place a padded, 
angular splint, similar to that recommended hereafter 
for fracture of the condyle, on the inside or front 
of the arm, and let it extend from the axilla or shoul- 
der to the ends of the fingers. Place, also, three 
splints of the length of the humerus, on the remain- 
ing three sides of the arm, and bind them all to the 
limb by the ordinary spiral bandage, commencing 
at the wrist and extending to the shoulder. This 
plan ensures the most perfect rest of the elbow-joint 
and consequently of the fractured fragments ; but to 
guard against the stiffness likely to result from a 
permanent rest of the joint, the angle of the splint 
should be varied at least every week. It must, how- 
ever, be recollected that this, like the dressing of 
Boyer, is only applicable to fractures of the shaft of 
the humerus, that is, of the portion below the inser- 
tion of the pectoralis major muscle. 

FRACTURE OF THE CONDYLE-(PHYSICK'S METHOD). 

The position of the condyles to the elbow-joint 
renders the treatment of this fracture a matter of 
great importance ; as, without proper attention, the 
inflamation may extend to the joint, produce anchy- 
losis, and deprive the patient of the use of the limb. 



226 OF FRACTURES OF THE 

When the fracture is simple, a good method of treat- 
ing it will be found in that proposed by the late Dr. 
Physick, which is as follows : 

Flex the forearm on the arm so as to relax the 
flexor and extensor muscles, and apply a bandage 
from the fingers up to the shoulder by spiral reversed 
turns, making a figure of 8 around the elbow. Then 
prepare two angular splints like Fig. 150, of the 
same angle as that which the forearm takes when 
flexed, and covering them well with cotton on the 
side which is to be placed next to the limb, apply 
one on the inside, and the other on the outside of 

the arm, from the shoul- 
Fi 0- 15 °- der down to the fingers, 

confining them by an- 
other spiral bandage 
exactly like that of the 
Spiral of the Upper Ex- 
tremity. The forearm 
being now brought across the chest, should be placed in 
a sling, with the palm of the hand next to the front of 
the chest, and the thumb pointing upwards ; when the 
patient may walk about as usual, if free from pain. In 
using this splint great attention must be paid to the 
state of the internal condyle, which, unless the splint 
is well padded, is very apt to cause ulceration of the 
skin from pressure on its point. The angle, also, 
of the splint should be changed, as before directed, 
after the first ten days, in order to prevent anything 
like anchylosis. 

Whenever the splint just described produces ex- 
coriation, or when the wants of the surgeon may ren- 
der a single splint more desirable than a set of those 
of varying angles, the one figured in the accompany- 
ing cut will prove of great utility. It is to be applied 
to the front of the arm, and its angle varied as occa- 
sion may require, simply by shifting the wire which 




UPPER EXTREMITY. 



227 



is fastened to the arm portion in the holes on the 
part found on the front of the forearm. 

Fig. 151. 





When fracture of the condyles is complicated with 
contusion of the joint, or when it is compound, abetter 
plan of treatment will be found in the use of a carved 
angular splint like Fig. 152, in which the arm may lie, 
loosely confined by a few strips of Scultet's band- 
age ; while leeches, cold 
washes, &c, may be ap- 
plied to the part, in order 
to combat the inflamma- 
tion. Or it may be sim- 
ply flexed andlaid on a pil- 
low, till the swelling is re- 
duced; and then be treat- 
ed as a simple fracture. 

In order to make this carved splint, or in order 
to make a carved splint for any of the limbs, pursue 
the following plan : Lay the limb on or against a 
piece of stiff' paper, or soft wood, and mark its out- 
line with a pencil, tracing acurately its angles, promi- 
nences, &c, by running the pencil over its surface. 
Then seeing that the wood is thick enough to allow 
of its being hollowed out, so as to embrace at least 
one-half of the circumference of the limb, scoop out 
the wood in the lines of the pencil, shave off the 
outside with a spoke-shaver or gouge, so as to 



228 OF FRACTURES OF THE 

render it thinner and lighter ; after which a piece 
of linen or muslin should be pasted over the outside 
to prevent its splitting from moisture, the inside 
being covered in the same way with soft buckskin to 
prevent the chafing of the skin on the wood. 

These splints will be found of great utility in the 
treatment of injuries in the neighborhood of joints, 
and so simple that any one of the least mechanical 
ingenuity can make one that will answer the purpose 
very well, though the aid of a professed carver is 
desirable when a very light and perfect splint is re- 
quired. Binder's board, tin, &c, are frequently used 
for the same purpose, but do not form as neat a 
dressing, and are also liable to be bent out of shape. 

Several additions have lately been made to the 
list of articles especially suited to the purpose of 
splints for the preservation of rest in or about joints, 
such as felt, coated with gum shellac, brown paper 
plastered with starch or glue, &c. But though all 
may be occasionally useful, few, in my opinion, can 
be more readily or neatly adapted to the part than 
the Gutta Percha. When a strip of this, about one- 
eighth or one-quarter of an inch thick, is soaked for 
a few minutes in boiling water, it becomes almost as 
flexible as cloth ; and being in this state applied to 
the body, adapts itself acurately to its shape, where 
in a few minutes it will become quite as stiff as thin 
board. 

FRACTURES OF THE FOREARM. 

Fracture of one or both bones of the forearm are 
usually dressed exactly in the same manner, with the 
exception of fractures of the lower end of the radius, 
or of the olecranon. In treating a fracture of both 
bones, reduce the fracture by means of extension at 
the wrist, and counter-extension at the elbow ; 
knead the muscles into the interosseous space in 
order to preserve it. Then, according to the plan 
of the Pennsylvania Hospital, take two straight 



UPPER EXTREMITY. 229 

splints, long enough to extend from the bend of the 
elbow to the extremity of the fingers, half an inch 
wider than the forearm, and well padded with cotton, 
the latter being confined to the splints by a roller, 
and thickest in the middle, so as to act as a pyra- 
midal compress on the interosseous space. Then 
apply one of these padded splints on the front, the 
other on the back of the forearm, whilst it is in a 
state between supination and pronation, or, in other 
words, while the bones are perfectly parallel, and 
confine them there by a roller which should be only 
moderately tight at first, so as to guard against swell- 
ing. Then after the lapse of a week, draw the roller 
more firmly, so as to cause the padding of the splints 
to act on the interosseous space, but be careful 
that it is not too tight, and continue this dressing 
till the case is cured. The case of amputation of 
the arm, consequent upon the mal-application of the 
roller in a simple fracture of the radius, as before 
mentioned, should caution us against the use of too 
much traction in the application of the bandage, 
especially immediately after the occurrence of the 
injury. 

FRACTURE OF THE LOWER END OF THE RADIUS, OR 
BARTON'S FRACTURE. 

This fracture often similates a sub-dislocation of 

Fig. 153. 




the wrist, owing to the falling of the hand, as seen 
in the cut, and so frequent is it, that eight out of ten 
20 



230 OF FRACTURES OF THE 

of the supposed sub-dislocations of the wrist will pro- 
bably be found to be fractures of this kind. For the 
best treatment of it we are indebted to Dr. J. Rhea 
Barton. His apparatus consists of two compresses, 
about three inches by two, or else two and a-half 
inches square, graduated from one end, and two 
splints prepared as in fracture of both bones of the 
forearm ; together with a two and a-half inch roller. 
Then place one of the compresses on the front of 
the wrist, with its thick end downwards, about one- 
eighth of an inch above the articulating end of the 
radius; place the other on the back of the wrist, 
with its thick end upwards, so that it may be on a 
line with the upper row of the bones of the carpus, 
or on a line with the end of the first compress, and so 
that one may begin where the other ends, though on 
opposite sides of the wrist. Fasten these by a few 
turns of a roller loosely applied around the hand and 
wrist ; then place the two splints in their position, one 
on the front, the other on the back of the forearm, 
extending them from the fingers up to the elbow, 
and bind them there by the spiral bandage, as in 
fracture of both bones of the forearm. After a 
few days, increase the tightness of the bandage 
moderately and make a slight extension of the joint, in 
order to prevent anchylosis. If instead of the bulg- 
ing on the back of the hand, as generally seen, it 
should be on its front, we have only to change the 
relative position of the compresses, and then pursue 
the same plan. 

FRACTURE OF THE METACARPAL BONES 

Is generally caused by heavy weights falling on them, 
and producing such a degree of contusion as to re- 
quire our closest attention to combat the inflammation. 
In this case, we should employ a splint carved out to 
fit the forearm and hand, placing a small mass of 
cotton under the palm, so as to preserve its concave 



UPPER EXTREMITY. 231 

character, and then allow the limb to be open in the 
splint, till by leeches, cold washes, &c, we have re- 
duced the inflammation. If, however, the fracture is 
produced by a fall on the hand we shall most fre- 
quently find the fracture in that of the little finger, 
this being one extremity of the arch formed by the 
metacarpal bones, and the one most exposed to the 
shock in falling. To dress this accident, place a mass 
of cotton in the hollow of the hand, and bandage the 
limb to a splint with a broad palmette or hand-piece ; 
taking care that the splint extends from the ends of the 
fingers, up to near the elbow, in order to prevent 
the action of the flexor muscles. 

FRACTURES OF THE PHALANGES, 

If simple, should be treated by first covering the 
finger with a spiral bandage, and then keeping it in 
a proper position by means of four small splints of 
binder's board; those on the front and back of the 
finger reaching from its extremity as high as the 
wrist, but the two lateral ones extending only the 
length of the finger. All these being padded with 
cotton should be confined by a second spiral of the 
fingers, the roller in each case being under an inch 
in width. Attention should be especially given in 
these fractures to the state of the joints, and passive 
motion be early made, as a stiff finger is a most seri- 
ous inconvenience. 

FRACTURE OF THE OLECRANON. 

In this injury the upper fragment is drawn up by 
the action of the triceps muscle. All the means of 
treatment have, therefore, the same object, viz., the 
bringing it down, or the placing of the two fragments 
as closely in contact as possible, in order to diminish 
the amount of ligamentous union. When from ex- 
coriation, or other accidents, one method is not avail- 



232 



OF FRACTURES OF THE 



Fig. 154. 



able another may be substituted, as all have some 
points which recommend them in particular cases. 

SIR ASTLEY COOPER'S APPARATUS 

Is composed of two strips of muslin, or tape, each about 
half a yard long ; of two short rollers ; of another 
roller of the ordinary length, and a light splint made 
sufficiently long to extend from the 
margin of the axilla about half way 
down the forearm. Then, the pa- 
tient's forearm being extended, and 
the upper fragment pressed down 
until it touches the shaft of the 
ulna, a strip of linen is to be ap- 
plied above and below the joint, 
and one of the short rollers 
passed round the limb above, and 
the other below the olecranon, to 
secure them, as at b b. The ex- 
tremities of each tape being reflec- 
ted and tied together, as at a, draw 
the rollers nearer to each other, 
and place the upper fragment of the 
olecranon in the closest apposition 
possible to the lower. Lastly, the 
split splint, c, well padded, is to 
be applied along the front of the 
arm, and secured by a bandage, d d, the latter 
being frequently wetted with an evaporating lotion. 
Care should be taken in setting this fracture to pre- 
vent the integuments being pinched between the 
fragments, lest it should prevent their union. 

DESSAULT'S APPARATUS FOR THE SAME 

Consists of a strong pasteboard splint long enough 
to cover a part of the arm and forearm, and shaped 
so as to accommodate itself to the bend of the elbow, 
when the arm is in a semiflexed position ; and of a 




UPPER EXTREMITY. 233 

roller five or six yards long and two and a-half inches 
wide, with some compresses or lint. Then whilst 
the limb is maintained by two assistants in semiflex- 
ion, the surgeon proceeds to cover in the hand and 
forearm with the roller ; as he approaches the elbow 
an assistant draws the skin, which is here usually 
wrinkled, gently upward, to prevent it being caught 
between the fragments, and the surgeon pushes 
down the fractured extremity of the olecranon, in 
order to place it in contact with the body of the ulna. 
He now confines it in this situation by means of a 
few turns of the roller, carried round the joint in 
form of a figure of 8, as in the bandage for phlebo- 
tomy ; and the elbow being at length covered, carries 
the roller spirally as far as the axilla, in order to 
compress the triceps, and prevent its action on the 
upper fragment. The carved splint being then well 
padded with the lint or compresses, is applied along 
the front of the arm and forearm, and fixed by a 
succession of oblique turns of the remainder of the 
roller, carried down to the wrist. 

THE HOSPITAL APPARATUS. 

At the Pennsylvania Hospital, the apparatus for 
the treatment of this injury consists of two, two and 
a-half inch rollers ; a splint to extend from the mid- 
dle of the arm to below the middle of the forearm, of 
the width of the arm ; and of some cotton or tow, to 
fill up the hollow at the bend of the arm. 

The forearm being then extended on the arm, and 
the upper fragment brought down, and held by an 
assistant, apply the ordinary Spiral of the Upper 
Extremity from the fingers up to the shoulder, making 
figure of eight turns around the elbow so as to keep 
the fragments in apposition, and applying the ban- 
dage firmly around the arm, to prevent the action of 
the triceps. ^ Then apply the tow to the bend of the 
arm, and bind the padded splint on its front by a 
20* 



234 OF FRACTURES OF THE 

second spiral bandage. After ten or twelve days, 
a slight degree of flexion is to be made at the elbow and 
gradually increased to prevent stiffness, the fracture 
being maintained in its position by the fingers of the 
surgeon, during this movement. 

BOYER'S METHOD. 

According to this surgeon, the indications are to 
keep the fragments as closely as possible in apposi- 
tion, without uselessly fatiguing the muscles by com- 
plete and constant extension of the forearm; and 
also by rest, to favour the formation of the ligamen- 
tous substance, without allowing the joint to become 
stiff. 

In order to do this he advises that the forearm 
should be slightly flexed on the arm, so as to make 
an obtuse angle with it, and then an ordinary spiral 
bandage applied from the fingers to the elbow. The 
fragment being now drawn down, a narrow strip, or 
long compress, is placed behind it, and fastened by 
crossing its ends in a figure of 8 around the forearm ; 
after which the bandage is continued over it in the 
form of several figures of 8, and then carried by 
spiral turns up to the shoulder, so as to compress the 
triceps. To guard against anchylosis, motion should 
be made at the joint about the twentieth day, and at 
the forty-fifth the cure is usually complete; the 
union being then quite firm and, as he says, as solid 
as it ever will be. Should there be much swelling or 
pain he advises that the bandage should not be 
applied, or the reduction of the fracture attempted, 
but the limb be simply placed on a pillow, and the 
inflammation treated by local means. If the inflam- 
mation does not disappear by the twentieth day 
the case may be left to nature ; a number of instances, 
which he reports, having shown that even when 
thus left it will gain as much strength and freedom 
of movement as when confined more closely. 



UPPER EXTREMITY. 235 



THE CARPO-OLECRANIEN HANDKERCHIEF OF M. MAYOR 

Has been already mentioned. It will answer very 
well, in many cases of this fracture, as a provisional 
dressing. 

THE UNITING BANDAGE OF GERDY 

For transverse wounds and for fractured patella is 
also applicable here, but as its use is more frequent 
in the patella than elsewhere, I shall reserve its 
description until I treat of that accident. 

When the fracture of the olecranon is compound, 
or complicated with severe contusion, the effects of 
the inflammation on the joint renders its treatment 
the most important indication, and it will be better, 
therefore, to place the limb in the carved angular 
splint before spoken of, and confine it by a few 
strips of Scultet's bandage, employing leeches, cold 
washes, &c, as in compound fractures of the condyles 
of the humerus, than to use either of the dressings 
just mentioned. 

FRACTURE OF THE CORONOID PROCESS OF THE ULNA, 

If it should ever be found, will be recognized by its 
simulating dislocation of the bones of the forearm 
backwards. By pulling the forearm, and at the 
same time flexing it, the dislocation is easily reduced, 
but returns again immediately on the force being 
removed. In order to prevent this, flex the forearm 
on the arm, using the angular splint directed for the 
front of the arm in fracture of the condyles, and 
binding it firmly, so as to keep the elbow flexed for 
several weeks ; the action of the brachialis internus, 
which is liable to reproduce the deformity, being pre- 
vented by the turns at the elbow. This accident is, 
however, a very rare one, Dr. Physick having seen 
but one case which he thus treated, and Sir A. 
Cooper and Mr. Liston having, also, seen but one cr 



236 FRACTURES OF THE UPPER EXTREMITY. 

two instances of it. From considerable observation 
I am induced to believe that a fracture directly 
through the greater sigmoid cavity of the humerus 
has been often mistaken for this injury, and though 
I cannot deny the examples cited, a practioner should 
be on his guard when anticipating the existence of 
fracture of the coronoid. 

For remarks on the Diagnosis of Injuries of the 
Elbow, see Dislocations of the Forearm. 



CHAPTER IV. 

OF FRACTURES OF THE LOWER EXTREMITY. 

In few cases requiring surgical attention has there 
been as great a variety in the plans of treatment 
as in the fractures to which I now refer. Almost 
every year, and from every section of the country, 
we have accounts of some new modification, or 
some " decided improvement in their apparatus, 
which, in the opinion of the inventor, and from 
the decided testimony of one or two perfectly 
cured cases, must supplant everything heretofore 
known ;" when, perhaps, the great and improved mo- 
dification, consists only in the substitution of narrow 
strips for broad bands, or in the difference of a buckle, 
or the peculiar shape of a hinge. To refer, then, to 
all these, would be as useless as uninteresting ; and 
I shall, therefore, present only the more original 
plans, premising a few remarks on the duties of the 
surgeon in the preparation of the general means 
requisite for their treatment. 

When called to a fracture, or even a supposed 
fracture of the lower extremity, our first duty should 
be to consider in what way the patient may be most 
readily moved and prepared for his dressing, and 2d, 
how that dressing is to be obtained. 

1st. How are we to prepare for the removal and 
dressing of the patient ? 

In injuries of this nature, a shutter, door, frame, 
or settee, is usually selected, on which the patient 
is placed encumbered with his ordinary dress, and 
as we know that for the proper treatment of his case 
perfect repose of the limb is absolutely essential, 



238 OF FRACTURES OF THE 

our thoughts naturally turn to his place of rest during 
the treatment, and to the selection of the bedstead 
and bed. The first will be readily found in the or- 
dinary single bedstead, provided it is low and narrow, 
with a low head-board, and without a foot-board. 
This should be made into what is called a Fracture 
Bedstead, by first drawing the sacking-bottom as 
tightly and drum-like as possible ; or if slats can be 
had, by placing them in their position, and cutting 
in the centre of either a hole large enough to admit 
a pot ; then nail on the underside of the bedstead, at 
a distance corresponding with the width of the pot, 
two strips grooved or ploughed like the strips in 
which an ordinary counter-draw runs, so that they 
may receive the rim of the pot, and allow of its sli- 
ding in and out under the patient ; or a closed stool, 
or pot concealed in a box, may be placed beneath 
the opening when it is required, and raised to the 
proper height by placing stones beneath it. If a 
number of these bedsteads are required, as in a hos- 
pital, it will be found most useful and cleanly to 
have them made of iron, as they are more readily 
preserved from bugs, &c, 

After the bedstead, we should next prepare a hair 
or firm and even mattress to fit it, by cutting out a 
piece of the mattress to correspond with the hole in 
the frame of the bedstead, sewing the cut edges of 
the ticking together, and stuffing it so that the edges 
of the hole may not be hard or likely to chafe the 
buttocks. We then place over this a sheet with a 
similar hole in its centre, and arrange on it the pre- 
liminary portions of the apparatus to be used ; after 
which attention may be given more immediately to the 
treatment of the patient. Having carefully removed 
his clothes, &c, we should prepare to remove him to 
the bed. To do this properly, see that the open side 
of the settee corresponds with the side of the bed, 
and the head of the patient with its head, especially 



LOWER EXTREMITY. 239 

if the room is narrow ; otherwise we may be com- 
pelled to carry the settee out of the chamber, and 
perhaps down stairs, in order to turn it, as I have 
occasionally seen done, at the expense of much un- 
necessary pain and trouble. We next procure three 
assistants, and having informed them of their duties, 
place one at each shoulder of the patient, so that 
they may face each other, the third being at the 
limb on the sound side, and the surgeon himself 
taking charge of the injured limb. Then direct the 
two assistants at the shoulders to pass one of their 
arms under the patient's neck and shoulders; let 
them slide the other hand under his buttock, and 
clasp each other's fingers in what is known as the 
sailor's grip, or, in other words, grasp hands by 
making the palmar side of their fingers touch. 

The third assistant, now holding the sound limb, 
let the surgeon place one hand under the seat of 
fracture, the other under the calf of the leg, if the 
fracture is in the femur, and at the word to move, 
let the assistants lift and carry the patient down to 
the foot of the settee, so as to get free from it, and 
then passing, one on each side of the narrow bed- 
stead, place their burthen so that the lower part of 
his buttocks may correspond with the upper edge of 
the hole in the mattress, when the dressings may be 
readily applied. If instead of a fractured thigh it 
is a fractured leg, the arrangements should be the 
same, except that the surgeon should grasp the leg 
with both hands, one being at the knee and the 
other just below the seat of the fracture, or at the 
ankle. 

Although these directions may seem minute, yet 
are they absolutely necessary to prevent the suffer- 
ing of the patient, and the awkwardness which is too 
apt to result from a want of attention to them ; as- 
sistants or inconsiderate surgeons very often so 
placing themselves, that on moving the patient they 
come directly between him and the bed, thus neces- 



240 



OF FRACTURES OF, ETC. 



Fig. 155. 



sitating their lying down, or crawling across the bed 
in order to get out of the way. 

Where it is found difficult to prepare the bed as 
thus directed, a very excellent and simple substitute 
will be found in a frame made of sacking or strong 
cloth, nailed on two narrow strips several inches 
longer than the bed, and joined by two transverse 
pieces a little wider than the bed. 

This being placed on an ordinary firm mattress, 
and a sheet with a central hole placed 
over it, the patient will lie as on an 
ordinary bed till he requires a stool, 
when assistants at the head and foot 
of the bed, by raising the frame like 
^<a\ an ordinary hand-barrow, and plac- 
ing its ends (Fig. 155) on four heavy 
chairs, can readily air the bed, or 
even remove it, and of course can 
also easily pass a pan under the 
frame to receive the discharges. 

Having now completed these ar- 
rangements we should proceed to 
the second head, or the 

Preparation and application of 
the apparatus. 

The kind of apparatus required 
for the treatment of a fracture must 
necessarily depend upon the injury. 
In fracture of the femur below its 
neck, the extended position, as re- 
commended by the French surgeons, 
is almost the only one employed, as far as I know, in 
the United States ; the apparatus of Dessault, as 
modified by Drs. Physick and Hutchinson ; the ap- 
paratus of Boyer, modified by Hartshorne ; or that 
of Hagedorn, modified by Prof. Gibson, being those 
most frequently used in this city, though I have oc- 
casionally seen the plan of Amesbury, and of Prof. 
Nathan R. Smith, in use, in special cases. 




CHAPTER V. 

OF FRACTURES OF THE FEMUR. 
IN FRACTURES OP THE NECK OF THE FEMUR, 

Within the capsule, especially in old persons, as the 
union will generally be ligamentous, it is sufficient 
simply to bend the limb on itself on a double-in- 

Fig. 156. 




clined plane, such as that of Sir Charles Bell, Chap- 
man, of England (Fig. 156), Amesbury, &c, or to 
use the method of Dupuytren, in which a double- 
inclined plane is formed by cushions or pillows, 
covered by a common sheet. 

DUPUYTREN'S PLANE 

Is made by three or four cushions, decreasing in size 
from below upwards, placed under the ham ; and so 
disposed as to form a double-inclined plane. On the 
upper portion of this the thigh is made to repose, 
while the leg, in a state of flexion, rests upon the 
lower, and the limb is maintained in its position by 
means of a sheet folded like a cravat, the central 
21 



242 FRACTURES OF THE FEMUR. 

part of which embraces the foot, while the extremi- 
ties are attached to the sides of the bed. 

Simple, however, as this is, the plan frequently 
pursued by surgeons in this city is more so, and 
answers I believe equally well. It consists in dou- 
bling an ordinary pillow on itself, and placing it under 
the ham and leg, thus making a plane of the sim- 
plest kind, and giving, by the addition of a band to 
fix the foot, all that is requisite for the treatment of 
this injury. It has also the advantage of not causing 
excoriation by pressure, &c, and as the class among 
whom this accident is most frequently seen are ad- 
vanced in life, it is a point that should by no means 
be overlooked. 

In fractures of the shaft of the bone, the extended 
position being, as before stated, preferable to the 
flexed one, the treatment is entirely different. In this 
accident, owing to the shortening produced by the 
contraction of the powerful muscles which surround 
the bone, the surgeon is compelled to employ some 
means of making extension and counter-extension, 
as it is usually termed ; though, in reality, the means 
of extension should always be the hands of the sur- 
geon, and the bands be only used to preserve the 
extension when he has made it. 

To keep up extension, various bands have been 
employed, but it matters little of what they are 
made, provided they are flexible, soft, and porous, 
especially the latter, in order not unduly to promote 
the insensible perspiration, and thus favour excoria- 
tion. But as these qualities are seldom found united 
in the same article, most of the means of preserving 
extension are made of two substances, the best of 
which are brown holland linen, and buckskin. These 
maybe employed either as described under the band 
of Dr. Coates, or in the gaiter of Dr. Physick, which 
is a modification of that of Petit. 



FRACTURES OF THE FEMUR. 243 



DR. COATES' BAND FOR PRESERVING EXTENSION 

Is made of a piece of brown holland, slightly biassed, 
but leaving the central threads continuous through- 
out, from fifteen to eighteen inches long, if designed 
for an adult ; two inches wide in the middle and 
narrowing on each side, rapidly at first, then slowly, 
towards the extremities, wliich are an inch in width 
(Fig. 157). This should be lined throughout nearly 

Fig. 157. 




its whole length with thick buckskin, a very little 
wider than the linen, the latter being simply basted 
to the former by stitches which dip but half way 
through the skin, in order that they may not produce 
irritation, two pieces of tape, or webbing, each an inch 
wide, being then sewed securely to the ends of this 
band, so as to make it long enough to go over the 
lower end of the splint to which it is to be fastened. 
In applying it, place the centre over the tendo- 
Achillis, and bring the ends round above the mal- 
leoli, to the front of the ankle ; cross them on the 
top of the instep, and carrying them down, knot them 
beneath the hollow of the foot a short distance from 
the sole ; when the tapes may be carried over the 
end of the splint, and tied. 

Where this band cannot be readily obtained, a 
common silk or Madras handkerchief, folded into a 
similar shape and applied like this band, answers 
quite as well. But in some cases, owing to the irri- 
tability of the patient, or to the extension being 
made by the band instead of by the hands of the 
surgeon, or owing to a want of attention to the 



244 



FRACTURES OF THE FEMUR. 



Fig. 158. 



smoothness of the band, or extreme tenderness in 
the skin of the patient, excoriations will show them- 
selves. It is desirable, therefore, by changing the 
means of preserving extension, to bring the pressure 
to bear on different points, and we may then resort 
to what is known in Philadelphia as 

DR. PHYSICK'S GAITER. 

This is made of buckskin and kid, of cloth and buck- 
skin, or hollands and buckskin ; but in either case 
the buckskin should go next to the skin, as it is the 
softest, most porous, and flexible of all these sub- 
stances. Cut out of either of these substances two 
pieces of the shape of the figure, and make it eleven 
or twelve inches long at its greatest length, and eight 
inches at its least, for an adult, and about four 
inches in its other diameter. Work eye-let holes in 
the ends, to receive the cord which 
laces it to the ankle, and sew a piece 
of buckskin on the inside of one end, 
so that it may come under the lacing 
when the gaiter is applied, and thus 
prevent the cord from pressing on 
the skin. Lastly, sew on two broad 
tapes or bands, of about three-fourths 
of a yard long, in order to pass to the 
end of the splint. 
In applying it, place a layer of carded cotton on 
the surface which is to be next the skin, and lace the 
gaiter smoothly round the ankle, from an inch above 
the malleoli down on to the front of the instep. If 
the use of this causes pain we should at once look 
to it, and if a slight change in its arrangement does 
not relieve it, rub the heel with whiskey or some 
slightly stimulating liniment. But should it produce 
excoriation, we must then resort to some other band, 
such as the Handkerchief of Dr. Barton (Fig. 128) 
before treated of, and with these means of preserving 




FRACTURES OF THE FEMUR. 245 

extension, we shall probably have all that is neces- 
sary. Every practitioner, if he has had much expe- 
rience in the treatment of fractures of the thigh, will 
doubtless admit the necessity of watching closely 
against excoriations, and also the great importance 
of the extending force being made to act directly in 
the axis of the limb. I need, therefore, not apologise 
for recommending an additional mode of accomplish- 
ing this object. Form with a bandage of flannel four 
inches wide (if an adult) a series of figure of eight 
turns, embracing the leg and ankle or instep as in 
Fig. 61. Then stitch orpin firmly on the portion 
of this which covers the malleoli, two broad tapes, 
and tie them on the lower end of the splint, as be- 
fore directed. The extension will thus be made from 
the malleoli ; the bandage will be elastic, and, there- 
fore, not painful, and the perspiration being readily 
absorbed, there is but little tendency to that macera- 
tion of the cuticle which is so often the starting point 
of ulceration. 

Let us now look to the means of preserving counter- 
extension. The padded band of Dessault, or Boyer, 
the bandage doubled several times on its length, or 
the use of a thick cravat, may all be objected to as 
frequently causing excoriation of the part ; and I 
shall, therefore, confine myself to the consideration 
of Coates Perineal Band, which will be found to be 
one of the best means that we can employ. 

COATES' PERINEAL BAND 

Is made of a piece of brown holland long enough to 
go round the perineum, in the line of the groin, and 
reach above the crista ilii both before and behind. 
For an adult it should be three or four inches wide. 
Double this in its width, and sew the edges firmly 
together, leaving one end open and closing the other ; 
then turn it inside out like a bag, and pour in bran 
or chaff, sufficient to fill it lightly : then quilt one- 
21* 



246 FRACTURES OF THE FEMUR, 

third of the closed extremity so as to flatten it to 
the thickness of half an inch, and pour in a little 

Fig. 159. 




more bran, stuffing it firmly till the central third is 
quite round and firm. After this close the open end, 
and quilt the terminal one as before, attaching to 
each extremity two broad tapes three-fourths of a 
yard long. Next, take a piece of soft buckskin about 
three inches and a-half wide, and about half as long 
as the band ; double it, and stitch the edges together 
in order to form a tube with the ends open, so that 
when the band is about to be applied it may be 
slipped over and cover the part which is to press on 
the groin ; then the seam being turned aside from these 
parts, secure it firmly to the band by a few stitches. 
When soiled, the buckskin may be easily changed, 
without requiring a new band. 

The addition of this piece is a great improvement 
to the ordinary band, and, according to the experi- 
ence of the inventor, as well as from my own, seldom 
or ever produces irritation. 

Junct-Bags, or cushions, are intended to prevent 
the pressure of the splints against the sides of the 
limb, as well as to equalize lateral pressure. They 
are made of muslin of the length of the limb, or, 
rather, long enough to extend on its outside from 
the pelvis to the external malleolus, and on the 
inside from the perineum to a point a little above 
the same process internally. One end of the bag 
being sewed up, is then filled with bran or chaff till 
moderately full, and the open end being likewise 



FRACTURES OF THE FEMUR. 



247 



closed, will form a cushion of the width of the splint, 
and like Figure 160. 



Fig. 160. 



In connection with this subject, and before de- 
scribing what remains of the ap- 
paratus for fractures of the femur, 
I cannot omit referring to the re- 
marks of Dr. Coates in relation 
to the delay attending our pre- 
parations, as they contain points 
of much practical importance to 
the young surgeon. " There is 
scarcely ever," says he, " a neces- 
sity for rapid action in a case of 
fractured leg or thigh. But as it 
would be wrong to allow the pa- 
tient to undergo the gradual 
shortening of the limb from con- 
tinual muscular action, while the 
surgeon rides off for his splints, 
or while he superintends their pre- 
paration in the shop of some car- 
penter who never saw what he is 
required to make, let him secure 
the limb by temporary means, and 
thus save his patient the exquisite 
pain of involuntary motions ; the 
irritation from the pressure of the 
fragments upon lacerated muscles ; 
and the increased force required 
to overcome their contraction. 
Place the patient, therefore, on 
the bed diagonally, and with ex- 
tending and counter-extending bands, made of towels, 
handkerchiefs, &c, employ one head-post, and the 
opposite foot-post, for securing him. After which, 
the surgeon can proceed coolly and leisurely for his 
apparatus ; certain that his patient suffers but little, 
and that scarce anything is lost by delay." 



248 FRACTURES OF THE FEMUR. 

THE SPLINT CLOTH 

Is a piece of muslin a yard and a-half long, one yard 
wide, and intended to keep the splints together, by 
being wrapt around them. 

The rolling of the splints in the splint cloth is not 
unfrequently a matter of considerable difficulty, in 
consequence of the pyramidal shape of the splints. 
To accomplish it with certainty, lay the splint cloth 
on the floor and roll the external splint first ; being 
the least sloped it will generally be readily covered. 
Then hold it on its side in the position that it will 
take when applied to the limb, and stand the internal 
splint at the proper distance from it on the cloth. 
Let an assistant hold the external splint, and laying 
the inside splint flat, turn it over and over till it 
reaches the side of the cloth. Then wrapping it 
once or twice, make it turn back again till it reaches 
the position whence it started. It must be borne in 
mind by the young dresser, that the two splints should 
be most distant at their upper ends, in order to ac- 
commodate the greater size of the thigh. 

SCULTET'S BANDAGE, 

Which is also often necessary in the treatment of 
fractures of the thigh, is made of strips of muslin 
about three inches wide, and of a length gradually 
decreasing from the first piece. This strip should 
be long enough to go once and a third round the 
upper part of the limb, each succeeding portion being 
one inch shorter. To prepare and apply the strips 
lay them down on a pillow or board (so that the whole 
may be readily placed under the limb without being 
deranged), placing each strip so that it shall cover 
only one-third of the preceding one. Then placing 
the limb on these obliquely in regard to their length, 
in order to favour their application, commence at the 
lowest part of the limb, and gradually ascend, draw- 



FRACTURES OF THE FEMUR. 



249 



mg each strip moderately tight (Fig. 161). When 
it is necessary to change one or more of the strips, 



Fig. 161 




undo the bandage, and attaching the fresh band to 
the soiled one draw the latter out, and thus place the 
fresh one in its place without deranging the limb. 

THE EIGHTEEN-TAILED BANDAGE 

Consists of a strip three inches wide, and as long as 
the limb, to which are stitched crosswise eighteen or 
more strips of equal width, sufficiently long to make 
a turn and a-half about the part, and cover in each 
other by about two-thirds. It was formerly used for 
the same purposes as the bandage of Scultet, but has 
been supplanted by it in consequence of the impossi- 
bility of changing a single strip, owing to its attach- 
ment to the centre piece. 

The apparatus for fractured femur differ in their 
form. The Splints of Dessault consist of one for the 
outside of the limb, long enough to reach from the 
spine of the ilium to four inches beyond the foot ; 
and of another extending from the perineum to the 
sole of the foot, both of the width of the limb. In 
the upper part of the outside one are holes to receive 



250 FRACTURES OF THE FEMUR. 

the counter-extending band ; its lower end having only 
one hole, for the extending band. To these are added 
a splint for the front of the thigh, junct-bags, Scul- 
tet's bandage, &c, as shown in Fig. 162. 




Being liable to the objection of not preventing 
lateral inclination of the pelvis, they are now but 
seldom used except by the French surgeons. Their 
application is shown in the cut. 

PHYSICK'S SPLINTS 

Are a modification of these, the addition being in the 
length of the outer splint ; in consequence of which 
its end reaches nearly to the axilla, thus making the 
counter-extension more in the line of the body, and 
preventing any inclination to that side. The addi- 
tion, by Dr. Hutchinson, of a notched block over 
which the extending band is stretched, makes the 
direction of the extension more in the line of the 
limb. The remainder of the apparatus is the same 
as that just described. With slight modifications, 
this is the dressing now employed in the Pennsyl- 
vania Hospital; and as the experience of the large 
number of cases there treated proves it to be all that 
is requisite for simple fracture of the shaft of the bone, 
I can safely recommend it as the most simple of our 
means of treatment. 

In its application, having arranged the patient, 
the bed, and the apparatus, as before directed, place 



FRACTURES OF THE FEMUR. 251 

the patient on the fracture-bed with his buttocks cor- 
responding to the hole, and put the counter-extend- 
ing band of Coates in the groin of the injured side. 
Then roll the splints in the splint-cloth so that the 
splints may be of the proper distance apart, and give 
them to an assistant. Place the gaiter, &c, on the 
foot, and, seizing the limb above the ankle with both 
hands, draw it gradually and steadily down (whilst 
an assistant makes counter-extension by the perineal 
band) till the limb is nearly the length of the sound 
one, or till the spasmodic contraction of the muscles 
is overcome. This may require five or twenty minutes, 
after which the splints and splint-cloth should be slid 
under and up the sides of the limb by other assistants. 
The splints now lying flat on the bed, place the junct- 
bags on them, and make their stuffing to correspond 
with the prominences and depressions of the limb ; 
press the outer splint to the side of the limb against 
the junct-bag, and tie the counter-extending tapes 
through the holes at its upper part. Then the ex- 
tending tapes being passed over the block, and one 
of them through the hole at the lower end of the 
outer splint, both are to be tied on the extremity of 
the splint, so as to secure the extension gained by 
the hands of the surgeon ; he keeping up this exten- 
sion till the bands are fixed and the outer splint in its 
place. The junct-bag being then arranged on the 
inner splint, and it turned up against the side of the 
limb, pass three pieces of roller under the hollow of 
the knee and slide them up and down the limb to 
their position, tieing them on the side of the splints 
so as to keep the whole apparatus close to the limb, 
and thus prevent lateral deformity. Looking now 
to see that the patient's body is perfectly straight 
in regard to his limbs, which may be told by seeing 
that the two anterior superior spinous processes are 
on the same level, measure from them to the internal 
malleolus of each limb, to see what is the difference 



252 FRACTURES OF THE FEMUR. 

in their lengths. Then place a hoop, bent as in Fig. 
163, over the toes, to keep off the weight of the bed- 

Fig. 163. 




clothes, and the dressing is completed. If, after 
two or three days, or even ten days, we find there 
is still shortening of the limb, make the extension 
with the hands as before, and thus daily drawing on 
the limb, pull it down and tighten the bands till it 
is of the same length, or as much so as possible ; a 
difference of a quarter of an inch not being precep- 
tible in the gait of the patient. 

Generally the reduction of this fracture is com- 
pleted at the second visit; but I cannot too strongly 
caution the young surgeon against believing that the 
fractured femur will in all cases, or in the majority 
of them, be perfectly of the length of the sound one. 
In favourable cases the difference will scarcely be 
preceptible, but if attention is not paid to the posi- 
tion of the spinous processes he may readily deceive 
himself, and prove the limb as long or even longer 
than the sound one; a point of which some have 
boasted when speaking of the success of their treat- 
ment. If excoriation of the heel is likely to occur, 
the placing of a piece of kid spread with soap cerate 
on the part affected, or the substitution of some other 
means of preserving extension, so as to vary the 
point of pressure of the band, or daily frictions with 
soap liniment, should be resorted to. But during 



FRACTURES OF THE FEMUR. 253 

this process, or during any change in the apparatus, 
the extension and counter-extension should be care- 
fully maintained by the hands of assistants. 

In this method it is seen that the bandage of 
Scultetus, and other bandages, or short splints on the 
front or back of the thigh, are dispensed with ; no 
advantage being derived from their use in the ma- 
jority of cases ; whilst we can, owing to their absence, 
examine the state of the fracture ; apply cold washes 
to combat any inflammatory action, and yet not de- 
range the limb by their application. Should the 
case, however, prove one of very oblique fracture, 
and especially at the upper third of the bone, the 
anterior and posterior short splint, with the applica- 
tion of Scultet's bandage to the thigh will, I think, 
be found of great service. 

BOYER'S APPARATUS 

" Is composed of a splint of a particular construction 
for extending the limb ; a foot-board ; a padded belt 
or perineal band, which is buckled round the upper 
part of the thigh ; two common flat splints of the 
length of the limb, one for the anterior and the other 
for the internal part of the thigh ; and some junct- 
bags, tapes, and wadding. 

"The outside splint is about four feet long and 
three inches wide. Along half its length runs a 
groove about half an inch broad, the extremity of 
which is covered with iron ; to this groove a screw is 
adapted, which occupies its whole length, one end of 
it being supported against the plate of iron covering 
the extremity of the groove, and the other made to 
fit a handle by means of which it can be screwed up. 
On the inside of this splint a contrivance for holding 
up the foot-piece is fastened to the screw, and the 
upper part of the splint is received in a sort of pouch 
or bag adapted to the external side of the perineal 
or thigh-belt. The sole-piece, or foot-board, which 
22 



254 FRACTURES OF THE FEMUR. 

has two branches at its inferior part to steady it when 
resting on the bed, is made of iron, and covered with 
soft leather. This is connected by means of a me- 
chanical contrivance, as just mentioned, with the 
screw. To that part of the sole which is near the 
heel is attached a broad piece of soft leather, which 
being split on each side into two straps, serves for 
fixing the sole to the foot. 

"The perineal band is of strong leather, covered 
with buckskin, and well stuffed with wool ; near the 
place where its two ends are buckled together on the 
limb a little leather pocket is sewed for receiving the 
upper end of the external splint. The patient being 
then properly disposed upon the bed, a splint-cloth 
is passed under the limb, and laid upon five tapes. 
In the next place the perineal band is applied, the 
surgeon having previously surrounded the upper part 
of the limb obliquely with a cushion of wadding, four 
fingers' breadth wide, and the length of the thigh- 
belt, or with the junct-bag, in order to moderate the 
pressure of the latter, and render it more support- 
able. The hollows of the sole of the foot and lower 
part of the leg are also filled up with wadding or tow, 
and the foot-piece is fastened to the former by means 
of the soft leather straps attached to its under sur- 
face, which pass round the lower part of the leg. 
Should, however, these straps appear insufficient to 
fix the iron sole firmly to the foot, an extra band of 
calico or linen may be applied in the same manner 
(Fig. 164). 

" That done, the surgeon proceeds to the reduc- 
tion of the fracture, and after adapting the upper 
extremity of the splint to the pouch of the perineal 
band, the foot-support being connected with the splint, 
and the cushions, and the anterior and internal splints 
applied, the whole is fixed by means of the tapes, as 
in the ordinary apparatus for fractures of the thigh. 
Lastly, by turning the winch, the iron sole is lowered, 



FRACTURES OF THE FEMUR. 



255 



drawing the foot, to which it is attached, along with 
it ; and the superior extremity of the splint being 



Fig. 164. 




pushed upward the member can be elongated to the 
necessary extent." 

HARTSHORNE'S SPLINTS. 

These are generally spoken of as a modification of 
Boyer's, but differ so much from them as to be almost 
entirely new. They are composed of an outer splint 
long enough to reach from four inches below the heel 
nearly to the axilla; and of an inner splint which 
goes from the same point up to the perineum. In 
the lower extremity of each of these is a long mor- 
tise in which the foot-board slides, or is moved by the 
screw. The upper end of the inner splint is covered 
with a pad of horse-hair, which is again covered by 
buckskin (Fig. 165). An ordinary gaiter and a hand- 

Fig. 165. 




kerchief complete the apparatus. In its application, 
fix the gaiter or band on the foot, and pass the splints 
on each side of the limb till the inner or padded one 



256 FRACTURES OF THE FEMUR. 

touches the perineum. Then attach the tapes of the 
gaiter to the upper block or foot-board, and by turn- 
ing the screw, draw it down, the limb following this 
movement till the perineum bears on the pad, when 
it is stopped, and the counter-extension made by 
means of the padded end of the inner splint. 

Junct-bags may be placed between the splints and 
the side of the body and limb if they press too much 
against it, but generally this is not the case, and in 
cases of compound fracture, where they would be 
soiled by the discharges, it is desirable to omit them. 
It is chiefly, I think, in cases of this kind, that these 
splints can be used to the greatest advantage, as the 
extension and counter-extension being kept up chiefly 
on the inner side, we can remove the outer splint, or 
cut out an oval piece corresponding with the wound, 
if on the outside of the thigh, and thus dress the 
wound, without taking off the extension. Care must, 
however, be observed in the use of this splint, that the 
pressure upon the integuments of the perineum does 
not produce a slough. 

AMESBURY'S APPARATUS FOR FRACTURES OF THE 
MIDDLE AND LOWER THIRD OF THE FEMUR 

" Is divided into three portions, independent of splints 
and straps ; one is for the thigh, a, Fig. 166 ; an- 
other for the leg, b; and the third for the foot, c. 
There are two thigh-pieces made to each apparatus, 

Fig. 166. 







one of which is bevelled ofif at the lower end 



FRACTURES OF THE FEMUR. 257 

right, and the other to the left ; so that when one of 
them is fixed to the leg-piece, which is hollowed out 
to receive the back of the leg, the leg and thigh-piece 
together are adapted to the natural line of the right 
limb ; and when the other thigh-piece is joined to 
the leg-piece, they are adapted to the natural line of 
the left limb. This arrangement Mr. Amesbury con- 
siders necessary, in order to preserve the figure of a 
perfectly-formed limb, which is not straight, but 
turns inwards a little at the knee. The leg and 
thigh portions are connected by means of a little 
steel or brass pin, d. Behind the apparatus is a steel 
bar, e, coated with brass, and fixed to the back of the 
leg-piece. To the upper end of this bar is fixed what 
Mr. Amesbury calls a brass foot, to which is attached 
a bolt acted upon by a spring. There is a hole in 
the centre of this brass foot, which is traversed by 
the bolt in the transverse direction. At the back of 
each thigh-piece is a rack, g, Fig. 167, with several 
projections, each having a hole bored through the 
middle, for the purpose of receiving the bolt attached 
to the brass foot-piece. The foot-piece is so connected 
with the steel bar that it may be easily fixed upon 
any of these projections. When fixed upon either 

Fig. 167. 




of these, except that nearest the leg-piece, the leg 
and thigh-pieces become joined together, so as to 
form a double-inclined plane (see Fig. 166) ; the angle 
of which may be varied at pleasure by altering the 
position of the brass foot-piece from one of the teeth 
or projections of the rack to another. At the upper 
end of the thigh-piece is a sliding brass plate, h, Fig. 
167, so adapted that it may be applied to either of 
22* 



258 FRACTURES OF THE FEMUR. 

the thigh-pieces at pleasure. This contrivance allows 
of the thigh part of the apparatus being adapted to 
thighs of various lengths. The upper end of this 
plate is turned off, so that, when it is properly padded, 
it may bear against the tuberosity of the ischium 
without injuring the integuments. At the back of 
the sliding plate are placed a couple of brass bars, 
i i, which answer the double purpose of rendering the 
sliding plate more secure when it is fixed upon the 
thigh-piece, and of preventing the pelvis strap, to be 
noticed presently, from slipping off the apparatus. 
There are little studs, ?, placed at the back of the 
apparatus, for the purpose of receiving the straps by 
which it is confined to the limb. 

" The pelvic strap is of leather, furnished with a 
sliding pad, and sufficiently long to reach round the 
thigh and the pelvis. 

" Three short splints long enough to reach from the 
upper end of the thigh to the lower part of the con- 
dyles of the femur are also required to be placed 
upon the thigh. 

"Application. — The apparatus and splints being 
properly padded, the surgeon places the pelvis-strap 
between the bars and the plate or sliding portion ; tak- 
ing care previously to apply a single-headed roller, d, 

Fig. 168. 




as in the cut, spirally about the leg, from the toes to 
the knee. This being done, an assistant takes the 



FRACTURES OF THE FEMUR. 259 

small of the leg in one hand ; places the other under 
the knee to raise the limb, and at the same time to 
keep the knee bent and the thigh extended, while the 
surgeon places the apparatus under it. When the 
limb is properly placed, the shoe, a (Fig. 168), pre- 
viously padded in the inside, is buckled to the foot, 
while the foot-board, b, and leg-piece, are placed at 
nearly right angles, in order to give the foot support 
and steadiness. The leg is then supported along the 
whole of its under surface in order to give it an equal 
bearing upon every point of the apparatus, and this 
is done by means of tow or wadding, c, placed under 
the small of the leg, between the long pad and the 
leg-piece. The leg is then fixed upon the apparatus 
by a roller carried spirally round both from the angle 
to the bend of the knee, or by straps properly padded. 
To confine the fractured parts in their natural posi- 
tion the assistant takes the apparatus and the knee 
between his hands, and extends the thigh gradually 
in a line with the thigh part of the apparatus, which 
the surgeon supports against the back of the limb. 
Then after coaptating the fragments of the bone he 
applies the splints ; the first, e, on the outer side of 
the thigh, from the great trochanter to the lower 
part of the outer condyle ; the second on its inner 
side, reaching from the pubes to the lower part of 
the inner condyle; and the third, /, upon the 
fore-part of the thigh, from a little below the supe- 
rior anterior spinous process of the ilium to the base 
of the patella. These splints are kept in place by 
the straps, g g g, fixed to the studs on the back part 
of the apparatus. Lastly, the pelvic strap, h, is to 
be carried round the limb, under the strips of leather 
of the splints, and made to cross on the outer side, 
while the buckle-end, with the sliding pad, is carried 
round the pelvis and made to meet the other end in 
front, where it should be fastened. The tapes, i i, 
serve for fixing the lower part of the apparatus to 
the foot of the bed." This and others of Mr. Ames- 



260 FRACTURES OF THE FEMUR. 

bury's apparatus, are thought by him to offer pecu- 
liar advantages ; and as he has written two large octavo 
volumes on the subject of fractures, I would refer 
those desirous of learning his views more fully, to the 
work itself. 

Several splints, very similar in principle to those 
of Mr. Amesbury's, are now manufactured to a con- 
siderable extent in some of our New England States, 
and circulated all over the country. As a general 
rule, they are objectional from their complicated cha- 
racter, and like those of Mr. Amesbury can only 
be prepared by the manufacturer, w T hilst those which 
are equally as good, can be made by any carpenter 
after the pattern of Drs. Physick and Hartshorne. 

GIBSON'S MODIFICATION OF HAGEDORN 

Consists in two splints half an inch thick, formed at 
the upper extremity like the head of a crutch ; five 
inches wide just below this head ; five feet and a-half 
long for an adult, and tapering towards the lower 
end, which is about two inches wide. These lower 
ends for the extent of a foot are straight, and have 
six or eight holes at equal distances large enough to 
receive a stout peg intended to secure the foot-board. 
Shoulders are made in the splint just above the last 
peg-hole, to prevent the foot-board from ascending. 
The foot-board itself is made of seasoned, tough wood, 
an inch thick, twelve inches long, and nine wide. 
In this are three rows of slits half an inch wide, and 
an inch and a-half long, intended for the straps of 
the gaiters which are to secure the feet to the board ; 
two other slits receive the ends of the splints, thus 
making eleven perforations in the foot-board.^ ^ The 
gaiters are like Physick's gaiter, with two additional 
straps ; so that there are two near the instep and 
two near the heel, long enough to pass through the 
foot-board and tie on its back. 

In its application, the bed being prepared, as be- 
fore mentioned, and the patient placed straightly on 



FRACTURES OF THE FEMUR. 



261 



it, the gaiters are applied to both feet, and the frac- 
ture set. The splints with junct-bags, or else the 
splints themselves padded, are then applied, and the 
sound limb bandaged all the way up to one splint, 
and then the foot-board fastened to both of them. 
The feet being protected by two small cushions be- 
neath them, are to be secured to the foot-board by 
passing the straps through the holes and tying them 
on the outside ; after which, both splints are to be 
secured to the patients body by four or five pieces 
of bandage (Fig. 169). The crutch-like heads are 

Fig. 169. 




merely so shaped to prevent accidental injury of the 
soft parts about the axilla, and have no reference, 
as many have supposed, to counter-extension. 

In this apparatus both limbs are confined, and the 
counter-extension is made at the acetabulum of the 
sound side by means of the sound limb. Conse- 
quently, we must guard against any bending of the 
sound knee, as that would at once do away with the 
use of this limb as a splint, and permit shortening. 
The addition of a short splint behind the knee-joint 
will be found an additional precaution against any 
flexion of this part. 

A very simple apparatus of the same surgeon, and 
especially well adapted to the treatment of fractures 
of both thighs, is to be found in the following plan : 



262 



FRACTURES OF THE FEMUR. 



GIBSON'S SIMPLE INCLINED PLANE 

Is composed of a board sixteen inches wide, two feet 
four inches high, and with six mortises near its upper 
extremity, which is placed vertically ; another board, 
of similar breadth and length, is placed horizontally ; 
and a third, three feet long, and extending from the 

Fig. 170. 




extremity of the horizontal one to within ten inches 
of the top of the upright one, forms an inclined plane : 
the whole joined together, forming a triangle (Fig. 

At the lower end of the inclined board is an open- 
ing six inches wide and eight long, to allow of the 
passage of faeces and urine to a vessel below. There 
are likewise two mattresses, two foot-cushions, and 
a pair of gaiters. The larger mattress, of the length 
and breadth of the inclined board, is two and a-half 
inches thick, and fastened to the board by straps on 
its edges. The smaller mattress fills up the open- 
ing for the passage of faeces, &c. The gaiters and 
foot-cushions are as before described; and lastly, 
there are two round pins, each six inches long, which 
are passed through holes in the inclined plane. Then 
the patient being placed on this, as seen in Fig. 170, 



FRACTURES OF THE FEMUR. 



263 



the fastening of the feet makes the extension, and 
the weight of the body the counter-extension, thus 
placing the limbs in an easy position ; in one very 
favourable to the reduction of any inflammation, 
and especially applicable to the cases of fracture 
just mentioned. 

When, from peculiar circumstances, we wish to 
allow a certain degree of motion to the limb, we may 
find it useful to employ the apparatus of 

NATHAN R. SMITH, OF BALTIMORE. 

" This consists of four pieces, viz. : two concave-in- 
clined planes, one of which is adapted to the inferior 
surface of the thigh, the other to that of the leg, and 
united by a hinge corresponding with the knee. The 
third piece is for the foot, and the fourth, connected 

Fig. 171. 




to the thigh-piece, extends up the side of the body 
(Fig. 171). The limb being placed in it, as in Fig. 
172, is then to be suspended." It is, however, a 
somewhat complicated apparatus, or at least one 
which, like the splints before mentioned, is not readily 
prepared at the moment. When applied, it makes, 
however, a very light and excellent double-inclined 



264 



FRACTURES OF THE FEMUR. 



plane. The figures give a good idea of it, and those 
who may wish to construct one will find a minute 
account of it, in all its parts, by Prof. Smith, in 
Gedding's Baltimore Med. and Surg. Journal, vol. i., 

Fig. 172. 




1833, and in the Transactions of the American 
National Medical Association, vol. ii., 1849. 



CHAPTER VI. 
FRACTURES OF THE PATELLA. 

In transverse fractures, the upper fragment being 
drawn up by the action of the quadriceps femoris, 
the indications in the treatment are to overcome 
the action of this muscle, and bring the fragments 
as closely in apposition as possible, in order to 
shorten the ligamentous union, and thus preserve a 
more perfect use of the limb. To do this, various 
means have been proposed by Dessault, Amesbury, 
Sir A. Cooper, Sir E. Home, Mogridge of Devon, 
Dorsey, Mayor, Gerdy, &c, &c. 

DESSAULT'S APPARATUS 

Consists of a splint three inches wide, long enough 
to reach from the tuber ischii beyond the heel; two, 
two and a-half inch rollers eight yards long ; a two 
inch band of the length of the limb, and some tow, 
&c. Then the thigh being bent on the pelvis, and 
the leg extended on the thigh, the limb is supported 
by an assistant, and the long band placed on the 
front of the limb, and held by other assistants in its 
place, until fixed by one of the rollers, in an ordinary 
spiral bandage, up to the knee. Two slits correspond- 
ing to the knee-pan are then made in the band, to 
allow the fingers of the surgeon to pass through and 
bring down the upper fragment, when the roller 
being resumed, should be carried round the joint in 
several figures of 8, and then continued up the thigh, 
to compress its muscles and fix the end of the band. 
The use of this band is now seen to be, to fix the 
turns of the roller, preventing those of the leg from 
23 



266 FRACTURES OF THE PATELLA. 

ascending, and those of the thigh from descend- 
ing, and also to guard against flexion of the knee ; 
to assist in which whilst the limb is still elevated, 
the surgeon applies one end of the splint under the 
tuber ischii, and then filling up the inequalities of 
the limb with cotton or tow, extends it on the whole 
back of the extremity, confining it to the limb by 
simple spiral turns of the second roller. 

This apparatus is very simple, but would perhaps 
answer as well without the band, the roller, if pro- 
perly applied, not being liable to slip after the appli- 
cation of the splint. 

DORSEY'S APPARATUS 

Is also simple, and consists of a piece of wood half 
an inch thick, three inches wide, and extending from 
the buttock to the heel. Near the middle of this 
splint two bands of strong muslin, about four inches 
wide each, doubled on itself, and a yard long, are 
nailed at a distance of six inches apart. Two ordi- 
nary rollers, two small compresses, and some tow or 
soft flannel, complete the apparatus. Then whilst 
an assistant raises the limb, as in Dessault's plan, 
the surgeon applies an ordinary spiral bandage to 
cover in the whole leg and foot, and on reaching the 
knee brings the fragments as closely together as 
possible, and confines them by figure of 8 turns. 
He then covers in the thigh by the same sort of 
turns; places the splint properly padded on the back 
of the limb, and fastens it by spiral turns of the 
second roller. On coming to the lower one of the 
transverse bands he passes it above the upper frag- 
ment, over the compress placed there, and then draws 
the upper strap below the lower fragment, both 
being secured by a pin or knot, after which the 
remainder of the splint is covered in by the subse- 
quent turns of the roller. 

This apparatus is the same in principle as Boyer's, 
but has the advantage over it of being more simple, 



FRACTURES OF THE PATELLA. 



267 



and easily obtained at a moment's notice ; a shingle 
or strip of wood, a few tacks, and a piece of bandage, 
being all that is requisite ; whilst it will be found to 
furnish a powerful means of approximating the frag- 
ments. 

MAYOR'S METHOD 

Has been already mentioned under his system as the 
tarso-patellse handkerchief. 

GERDY'S PLAN 

Is similar to the uniting bandage for transverse 
wounds, and consists of two strips about half a yard 
long, one of which is cut into 
three tails, and the other into Fi 9- 173 - 

three slits, and used as follows : 
Place an ordinary spiral bandage 
on the front of the leg as far as 
the knee ; then lay the tailed ban- 
dage so that its ends may corre- 
spond with the lower fragment, 
and fasten it to the leg by a se- 
cond spiral, firmly applied. Place 
a spiral bandage on the thigh, 
and laying the slit bandage so 
that its slits may correspond with 
the upper fragment, bind it by 
another spiral bandage, or by 
turns of the first, also firmly to 
the thigh. Place the two com- 
presses, one above the upper 
fragment, the other below the 
lower fragment, and passing the 
tails of one band through the 
slits of the other, press upon the 
compresses and force the frag- 
ments into apposition by fixing 
the lower, and bringing the upper 
one to it. Then confide the ends of the bands 




268 FRACTURES OF THE PATELLA. 

to an assistant, and fasten them by another spiral of 
the lower extremity, beginning at the ankle and 
reaching to the groin, with figure of 8 turns at the 
knee over the whole (Fig. 173). 



CHAPTER VII. 

FRACTURES OF THE LEG AND FOOT. 
FRACTURES OF THE LEG. 

These whether of one or both bones, with the 
exception of the lower end of the fibula, are usually 
treated in the same way. Here, as in other frac- 
tures, various means have been proposed, but as the 
most simple one has in my experience seldom or ever 
failed in effecting a perfect cure, I shall describe 
it first. 

The one to which I refer is sanctioned by the high 
authority of the Hospital, where fractures of the leg 
are extremely common, and where nothing else is 
employed except under very peculiar circumstances. 
Although the box is nothing new I shall name it, 
as applied in fractures of the leg, as the 

APPARATUS OF THE PENNSYLVANIA HOSPITAL. 

It consists of an ordinary pillow, and a fracture-box. 
The fracture-box is made of four pieces of wood, the 
bottom one of which, extending from the knee to a 
little beyond the heel, has fastened to its lower end 



Fig. 174. 




a perpendicular piece for the foot ; whilst to its sides 
23* 



270 FRACTURES OF THE LEG. 

are attached, by hinges, two lateral pieces about seven 
inches wide, which are intended to shut up against 
the sides- of the limb and foot-board, so as to form 
the box, Fig. 174. Where hinges are not convenient 
strips of leather will answer equally as well. In 
applying it, place a pillow in the box, and the limb 
on the pillow ; fasten the foot to the foot-board by a 
simple band over the instep ; tie up the sides of the 
box, and the dressing is complete. 

If it is desirable to apply cold washes in order to 
combat contusions, or to protect the pillow from dis- 
charges, in a case of compound fracture, a piece of 
oiled silk or coach curtain may be laid over the 
pillow. Otherwise it is not required. 

This very simple apparatus is all that has been 
employed in this large hospital for the treatment of 
fractures of the leg during very many years, except 
where, from great lateral inclination in fracture of the 
lower end of the fibula, Dupuytren's splint was neces- 
sary. But this has seldom been the case ; the tieing of 
of the foot to the foot-board, so as to give it an incli- 
nation inwards, and a little extra compression made at 
the internal malleolus by means of a pad of cotton, is 
all that is requisite, even in this often troublesome frac- 
ture. A very important point to be observed in the 
use of this apparatus, and one absolutely essential to 
its success, is the state of the heel, which being very 
apt to sink on the pillow, may thus cause the upper 
end of the lower fragment to project anteriorly. We 
must also see that the foot-board projects beyond the 
toes, in order to keep off the weight of the bed-clothes, 
and prevent their causing the same deformity by the 
extension of the foot. The band across the instep 
prevents the inclination of the foot to either side, 
and the pressure of the pillow against the limb by 
the sides of the box prevents lateral deviation of the 
fracture ; whilst having the parts constantly before 
us we can remedy instantly any deviation, or combat 
inflammation, by cold washes, &c. 



FRACTURES OF THE LEG. 271 

A simple rule by which to tell whether the bones 
of the leg are properly set or not, is to see that the 
edge of the first joint of the big toe corresponds 
with the inner edge of the patella. This, even if the 
patient is bandy-legged, will generally keep us right 
as to the proper position of the limb. 

In cases of fracture of the leg, where the contu- 
sion is a slight one, but accompanied by a wound, 
attempts should be made to close it as soon as possi- 
ble, and to promote its union by the first intention. 
To do this, draw the wound together with adhesive 
strips, and then apply over them a thick piece of 
patent lint, well wet with white of egg, so as to cause 
it to fit very closely to the limb, exclude the air, and 
form an artificial scab, as recommended by Sir A. 
Cooper. But since the introduction of Collodion no- 
thing of this kind will be required, except in the 
event of the practitioner not being able to obtain it. 
Neither of the applications should be removed for 
several days. Should the wound, however r be a seri- 
ous one, or proceeds to suppuration, no dressing will 
prove better than that of Dr. Barton. 

BARTON'S BRAN DRESSING. 

This requires a fracture-box ; some bran or fine saw- 
dust, and a little cotton. Then fill the box, with its 
sides shut up (or have one made with fixed sides), 
one-third full of bran ; place the limb in it, fasten 
the foot to the foot-board as before, and stuff some 
cotton between the knee and the sides of the box, to 
keep the bran from escaping. Then fill up the box 
with bran, so as to cover in the wound and whole 
limb. f 

This forms a very soft and equable bed for the 
limb, keeps the flies off from the wound, prevents the 
foetor from the discharges, and owing to its absorbing 
the blood or discharge from the wound, swells and 
makes pressure on the part, thus tending to arrest the 



272 FRACTURES OF THE LEG. 

hemorrhage, or prevent the formation of sinuses. 
After two or three days, if we wish to change the dress- 
ing, scrape off the bran from the limb, and cleansing 
it from the wound by a spatula or syringe, re-apply it 
fresh. In hospitals this dressing is especially useful, 
as it preserves the wards from the fcetor of the dis- 
charges, which without it would sometimes be almost 
insupportable. 

It also answers well for extensive wounds of the 
leg or thigh, the box, in the latter case, being made 
to extend up to the trochanter of the femur ; and in 
some cases, to my knowledge, has tended to prevent 
erysipelas, by keeping the limb from the action of 
the atmosphere. 

After the bony union in any case of fractured leg 
is tolerably firm, say after six weeks, an ordinary 
spiral bandage should be applied to the limb, and 
over this two splints of binder's board, or gutta 
percha, softened in hot water, should be confined by 
another bandage so as to mould themselves to the 
limb and strengthen the part, before the patient 
attempts to walk about. 

In very oblique fractures of both bones of the leg, 
extension and counter-extension is sometimes neces- 
sary to prevent shortening. To obviate this we may 
apply Physick's modification of Dessault's splints for 
fracture of the thigh, or Hutchinson's leg splints 
(though the first is preferable), till the tendency to 
spasm of the muscles has gone off, when the fracture- 
box may again be employed ; but I repeat, that in 
my experience it is seldom any other dressing than 
the simple fracture-box has been required even in 
these cases. 

HUTCHINSON'S SPLINTS. 

When, as just stated, the fracture is very oblique 
and especially if complicated with an attack of 
mania a potu, permanent extension may become 



FRACTURES OF THE LEG. 



273 



necessary, and advantages result from the use of the 
following apparatus, suggested many years since by 
Dr. Hutchinson: 

Two splints are to be made long enough to extend 
from the knee six or eight inches below the sole of 
the foot, with a mortise hole at the lower end of both 
splints, and four large gimlet holes at each of their 
upper extremities ; after which a strip about twelve 
inches long, two wide, and one thick, should be fitted 
to the mortise, and so perforated as to receive a peg 
in order to prevent the splints from separating. 
Then placing the leg on a pillow, which has previ- 
ously been covered by Scultet's bandage, let an 
assistant hold two pieces of tape eighteen inches long 
on each side of the knee, whilst the surgeon secures 
them by numerous circular turns of a roller, and 
placing the limb again on the pillow covers it with 
the bandage of strips from the ankle upwards. Let 
him now arrange the gaiter or extending band around 
the ankle, and tieing the tapes outside each splint 
by means of the four holes, draw upon the limb and 
tie the extending band to the cross strip, arranging 
the pegs so as to prevent the splints either from 
separating from each other, or pressing too closely 

Fig. 175. 




I- ■ • ■ ■■•' '"■'• -i 



on the limb. The cut shows very intelligibly the 
method of its application. 



274 FRACTURES OF THE LEG. 

Should the leg swell very much from the pressure 
of the circular bandage at the knee, Dessault's long 
splint may be substituted, and the counter extension 
made at the pelvis instead of below the knee. The 
apparatus is not, however, applicable to fractures 
near the knee or ankle-joints, on account of the pos- 
sible irritation of the extending and counter-extend- 
ing bands. 

AMESBURY'S APPARATUS FOR FRACTURES OF THE LEG 

Is composed of a thigh-piece, properly shaped to 
receive the back of the thigh, having a pair of lateral 
splints connected with it, and some studs for the 
retention of straps ; a leg-piece, immovably connected 
to the thigh-piece at an angle, and hollowed out for 
the reception of the back of the leg; and a foot- 
piece, which admits of being so shifted as to adapt 
the leg-piece to the length of the leg. This should 
not rise higher than is sufficient to form a right 
angle with the leg-piece when connected with it. 
There are some holes in each side, and a strap is 
attached to it, having upon one end a buckle, and a 
shoe with a wooden sole, for the reception and reten- 
tion of the foot, to which are attached two straps 
for connecting it with the foot-board. The foot- 
board is supported by a foot-strap, which, when in 
use, extends from one side of the thigh-piece round 
the lower part of the foot-board, where it is passed 
under a strip of leather placed there to keep it in its 
place, and then carried up to the opposite side of the 
thigh-piece, where it is buckled. 

The apparatus to be used ought to be first adapted 
to the sound limb in cases of simple fracture of the 
leg, and well padded as in the case of fracture of the 
thigh before referred to ; a small concave pad, too, 
should be placed on the inside heel of the shoe, and 
another pad upon the sole. Two side splints are re- 
quired, the outer one extending from the foot-board 



FRACTURES OF THE LEG. 275 

to the upper part of the outer condyle of the femur, 
and the inner one from the foot-board to the inner 
condyle ; — also a split deal shin-splint ; and in cases 
of oblique fracture, a thin pad to be applied upon the 
instep, covered with a piece of pasteboard, a little 
wetted, which, when dry, serves to equalize the pres- 
sure and keep the instep easy. 

Application. — In the first, or inflammatory stage, 
the shoe, a, containing the heel and sole-pads, ought 
to be carefully placed upon the foot ; the instep 
pad arranged upon the instep, and the shoe closed 
over it, and firmly confined to the foot by means of 

Fig. 176. 



the buckles and straps there attached for that pur- 
pose. An assistant should next be directed to place 
one hand under the knee, and, taking the foot in the 
other, raise the fractured limb, bringing it round so 
as to let it rest upon the heel. When the limb is 
raised the surgeon places the apparatus under it, 
and brings the angle of the same opposite the bend 
of the knee, directing the assistant to lower the limb 
upon the splint. 

He now neatly fixes the shoe, a, to the foot-board, 
b, by means of the straps attached to the sole, and 
by its aid is easily enabled to raise or lower the foot 
according to the length of the heel or thickness of 
the calf, so as to bring the lower portion of the frac- 
tured bones into a proper line with the upper, as far 



276 FRACTURES OF THE LEG. 

as respects any angular projection backward or for- 
ward, and a padded splint being placed upon the 
front of the thigh, the whole of the thigh-part of the 
apparatus is fixed to the limb by means of the straps, 
c. That done, the shoe fixed to the foot-board and 
the thigh part of the apparatus to the thigh, the 
foot-board may be raised nearly to a right angle 
with the leg-piece, and fastened in this position by 
the foot-strap, d, care being taken that the heel does 
not bear against the sole of the shoe. The fractured 
ends should next be noticed, and if the foot requires 
to be raised or lowered, it may be done by means 
of the strap which confines the shoe to the foot- 
board. 

The part of the pad, e, which lies under the small 
of the leg, being now raised and supported in close 
contact with it by means of tow or other soft material 
placed between the pad and this part of the appa- 
ratus, the whole length of the back of the leg will 
then have an equal bearing upon the apparatus. 

The lateral splints are next to be applied, the 
longest upon the outer side of the leg, and the 
shortest upon its inner side, the lower ends of these 
splints being fastened to the foot-board by means of 
narrow tapes passed through the holes at the sides, 
and the upper end kept close to the leg by the cir- 
cular strap, g, passed round the limb over the splints 
and the apparatus. 

With respect to the position of the limb thus fixed, 
it should be placed with the apparatus resting upon 
the heel, and the two planes be well connected, as 
seen in Fig. 176, by means of the steel bar, which 
forms part of the apparatus for fractures of the 
thigh, the whole being steadied by tapes attached to 
the foot-board, and passing off from thence to the 
sides of the foot of the bed. Cooling lotions, leeches, 
&c, may be applied, by unbuckling the circular leg- 
strap and throwing back the side-splints. 



FRACTURES OF THE LEG. 277 

When the inflammation is subdued, which is usually 
in three or four days, some strips of soap-plaster, each 
about an inch and a-half wide, should be applied 
round the limb with very moderate tightness, so 
that they may pass from the ankle to a consider- 
able distance above the fracture. The ends should 
then be crossed on the sides or front of the leg, and 
cut off, so as to be easily turned back, when it is ne- 
cessary to observe the state of the skin. Some 
strips, or a short roller, should also be passed round 
the foot to prevent oedematous swelling in that part. 
When this is done, and the side splints re-applied, 
the shin-splint should be properly adjusted, and the 
whole leg-part of the apparatus supported by three 
circular straps and buckles. 

The cross-bar may now be removed, and the appa- 
ratus furnished with a sling or thong of leather fixed 
to the lower end of the leg-part of the splint, by 
means of which the limb may be moved passively at 
pleasure, the patient reclining upon a sofa, or resting 
his leg upon the seat of a chair. He may walk, too, 
with the assistance of crutches, passing in this case 
the sling over the neck, as in the ordinary way ; the 
movements of the limb, however, should be always 
passive, and never by the action of its own muscles. 
In a fortnight or three weeks time, according to cir- 
cumstances, the foot-board should be shifted a little 
higher up the leg-piece, so as to press the fractured 
ends together, and hasten their consolidation. 

When both bones of the leg are broken, and the 
fracture of the tibia happens to be very oblique, ex- 
tension must be made until the fibula is united. For 
this purpose, the thigh-piece of the apparatus can 
be pressed up closely against the back of the thigh, 
and the foot-board shifted down, so as to make the 
space between the foot-board and the thigh-piece 
longer than the leg. When the limb is placed on 
the splint, and the thigh-piece fixed, the assistant 
24 



278 FRACTURES OF THE LEG. 

grasps the foot and ankle in his hands, and makes 
gentle extension in the natural line of the bone, so 
as to bring the fractured parts into proper adapta- 
tion ; this being done, the surgeon keeps up the ex- 
tension by buckling the strap, which is fixed trans- 
versely to the shoe, round the foot-board, taking 
care that the broken extremities unite in the rela- 
tive position which they naturally occupy. For fuller 
details relating to this part of the treatment, the 
reader is referred to Mr. Amesbury's " Practical 
remarks on the Nature and Treatment of Fractures 
of the Trunk and Extremities," vol. ii. 

DUPUYTREN'S APPARATUS FOR FRACTURES OF THE 
LOWER EXTREMITY OF THE FIBULA 

Consists of a wedged-shaped cushion, about two-thirds 
filled with bran or cotton, and of sufficient length to 
extend from the malleolus internus to the knee : of 
a strong splint about two feet long and three inches 

Fig. 177. 




wide ; and of two single-headed rollers from four to 
five yards long. 

Then the fracture being reduced, the wedge-shaped 
cushion, with the base directed downward, is to be 
applied along the inner side of the leg. The splint 
is next to be applied on this, and made to extend 
about four inches beyond the sole of the foot, and 
both bound fast to the limb by the application of 
one of the rollers in the form of the ordinary spiral 
bandage, from just below the knee to a short dis- 



FRACTURES OF THE LEG. 279 

tance, say one inch above the seat of fracture. Then 
with the remainder or with the other roller draw the 
foot in towards the splint, by figure of 8 turns of the 
instep and heel, maintaining it firmly in a state of 
permanent adduction. In Fig. 177 the turns of 
the upper roller do not come far enough down ; they 
should extend to within an inch or two of the frac- 
ture, but never cover the fracture lest the pressure 
at that point counteract the effect of the splint. 

DESSAULT'S APPARATUS FOR FRACTURE OF THE OS 
CALCIS 

Is made of a piece of a roller two inches wide, and 
of sufficient length to extend from four inches be- 
yond the foot to the lower third of the thigh ; — two 
single-headed rollers eight yards long and two and 
a-half inches wide ; and a strong, well padded, paste- 
board splint, moulded to the fore-part of the foot 
and leg, and reaching from the roots of the toes to 
a certain distance above the knee. 

Then the foot and leg being held by an assistant, 
the first in the most complete extension, and the 
second demi-flexed, another assistant should be re- 
quested to support the thigh, laying hold of it at its 
middle third. The surgeon then proceeds to apply 
a padding of lint, or charpie, over the toes, and ex- 
tends the strip of roller from the instep over the 
ends of the toes, well guarded along the sole of the 
foot, the back of the leg, and the lower and posterior 
part of the thigh, and the band being maintained 
thus by the assistants, the surgeon equalizes the 
posterior part of the ankle-joint by means of the 
padding, and applies the graduated compresses on 
each side of the tendo-Achillis. Next, taking one 
of the rollers, he fixes its initial end by a few circu- 
lar turns around the ankle, which at the same time 
secures this portion of the band, and reflecting the 
remainder of the latter backward, covers in the 



280 FRACTURES OF THE LEG. 

whole of the foot. He now passes several figures of 
8 about the heel, in order to embrace the separated 
portions of the bone and maintain them in apposi- 
tion, and then carrying the roller to a short distance 
above the knee by a simple spiral bandage of the leg, 
reflects the upper part of the band downwards, so as 
to fix it by a few horizontal circulars just below the 
knee. In the last place, the padded splint is placed 
upon the fore-part of the limb, and confined by a 
second roller, carried from the roots of the toes to 
the middle third of thigh, and the limb is extended 
over a pillow, so as to form a double-inclined plane. 

In fractures of the Metatarsal bones, or of the 
Toes, there is generally more occasion to combat 
the effects of injury to the soft parts than to set 
the fracture. We should, therefore, merely lay the 
limb in a fracture-box, and elevate it, to drain the 
blood from the part, applying cold washes, &c, to 
overcome the injury of the soft parts, and then keep 
it at rest against the foot-board. Caries is, however, 
very apt to follow such injuries even under appa- 
rently favourable circumstances. 

Fracture-bridges, etc., are often spoken of, to 
keep the weight of the clothes off the foot, and special 
directions given for their construction, but nothing 
more is necessary than two halves of a common hoop 
tied together in the centre, as shown in the fracture 
of the thigh by Physick's plan. 



CHAPTER VIII. 

OF THE IMMOVABLE APPARATUS, OR STARCH 
BANDAGE. 

Another method of treating fractures of the leg is 
by the now well-known method of Suetin, and Vel- 
peau, or the " Appareil Immobile." In the use of 
this apparatus, attention must be paid to the nature 
of the case, the constitution of the patient, &c. ; in 
other words, the surgeon must see that it is a favour- 
able case of simple fracture, and without much con- 
tusion. It should also be recollected that the band- 
ages used are to be those which have been pre- 
viously shrunk, and that they must be applied as in 
the French Spiral, page 81, so as to leave the heel 
and toes open to inspection ; and thus enable the 
surgeon to judge of the state of the parts above. 
In applying the bandages do it with a light hand, 
in order that they may not be too tight, and if the 
patient complains after their application, so as to 
show suffering, the whole must be removed. If thus 
applied, this dressing serves a most excellent pur- 
pose ; but is liable to abuse and to the production of 
serious dangers without great attention on the part 
of the surgeon, not only in its application, as I have 
here directed, but also throughout its continuance. 
Indeed, several cases have resulted most unfortu- 
nately, even in the hands of distinguished surgeons ; 
but with proper attention to the points italicised 
above, and the manner of applying it, the result will 
very generally be most gratifying. The success at- 
tendant on the cases in which I used it (and they 
were among the earliest in which it was tried in the 
24* 



282 IMMOVABLE APPARATUS, 

United States), may be best judged of from the fol- 
lowing report of them as treated in the surgical 
wards of the Pennsylvania Hospital, in 1838, at 
which time I was the house surgeon : 

Case First. — Fracture of both bones of the leg, 

George R , set. 34 years, a shoemaker by trade, * 

and of temperate habits, was admitted into the Hos- 
pital, Dec, 25th, 1838, with an oblique fracture of 
the tibia at its lower third, and one of the fibula at 
its upper third, caused by a fall upon the ice. The 
limb at first was placed in the fracture-box, and 
evaporating lotions used to reduce the inflamma- 
tion, which was considerable. On the third of 
January, seven days after the accident, the immova- 
ble apparatus was applied in the following manner : 
A washed roller, that is, one that had been well 
boiled and then dried, was smoothly applied from the 
toes to the knee, cotton being placed along the 
spine of the tibia, and also in the cavity on each 
side of the tendo-Achillis, to prevent excoriation from 
the turns of the bandage. This was then well rubbed 
on its outside with wheat starch, made thick and 
smooth by boiling for twenty minutes. A second 
roller was next applied from the knee down, and 
also well covered with starch. Two pieces of binder's 
board cut to fit the sides of the leg, and extend from 
below the knee to below the malleoli, were then 
soaked in water until soft, and being well saturated 
and rubbed with starch, applied to the leg over the 
bandages, so as to surround the limb, except for the 
breadth of a finger on the front and back ; small 
cuts being made at the lower end, to cause it to fit 
the projection of the malleoli, and also at any other 
point where it bulged out. A third splint, made to 
fit the foot, and slit at the end so as to enable it 
to turn up behind the heel, was then applied to the 



OR STARCH BANDAGE. 283 

foot and starched, and secured by a third roller from 
the toes up. This was coated in like manner ; a 
fourth bandage applied over all, and the dressing 
completed by starch, which kept the whole smooth 
and tight, without the aid of pins. 

The limb was now carefully laid in an empty frac- 
ture-box ; a little cotton placed under the heel, and 
the foot tied to the foot-board, where it was allowed 
to remain for four days, at the expiration of which 
period the whole was dry and hard ; the limb being 
cased as firmly as in plaster. 

The patient was then kept in bed without any 
other dressing except the splints ; and on the ninth 
of January, thirteen days after the injury, a bandage 
being doubled around his neck, carried down behind 
the calf of the leg, then in front of the ankle, over 
the instep, and round under the foot to the instep 
again, so as to form a sling and raise the foot a 
little from the ground, he was allowed to walk about 
with crutches. In this way he continued until 
February 7th, when the apparatus was taken off 
before the medical class in attendance on the prac- 
tice of the house, and the limb found perfectly straight 
and firm, without the slightest deformity. On the 
13th of February, seven weeks after the injury, the 
man was discharged. In this instance the apparatus 
was not touched until the fourth week, when a simple 
roller was applied to tighten it, owing to the loose- 
ness consequent on the shrinking of the muscles. 
One of the objections raised to the use of the appa- 
ratus was thus readily obviated without injury to 
the patient ; for as the splints did not meet before 
and behind the leg, it was easy to fold the surplus 
bandage in, without causing any welt on the skin ; 
while the bandages, having been previously washed, 
did not shrink to any extent. 



284 IMMOVABLE APPARATUS, 

Case Second. — Fracture of the fibula two inches 
above the joint. 

Patrick D , set. 42 years, a labourer, fell off 

a step on the 15th of January, and fractured his 
fibula obliquely, two inches above the external mal- 
leolus. Owing to the inflammation, leeches, and the 
antiphlogistic course, with the use of the fracture- 
box, were continued until February 1st, seventeen 
days after the accident, when the apparatus was ap- 
plied as in the preceding case, except that the splints 
were continued under the bottom of the foot ; being 
slit up so that the fold under the foot did not inter- 
fere with the application of the splint to the sole ; 
thus preventing all motion at the ankle-joint. After 
the apparatus had been dried in the fracture-box, 
with the foot well turned in, the patient was allowed 
to walk about, and on the tenth of February, twenty- 
six days after the accident, he walked up to the third 
story of the house, and was operated on by Dr. T. 
Harris for cataract. On February 21st, the appa- 
ratus was removed, there being not the least de- 
formity perceptible even to the touch. 

Case Third. — Oblique fracture of both bones of the 
leg. 

Patrick C , set. 23 years, a labourer, whilst 

working on a railroad on the 18th of January, was 
knocked down, by the caving in of a bank of earth, 
and both bones of his leg broken obliquely, near the 
middle. He was treated in the usual way by the 
fracture-box, until the 27th of January, when the 
starch dressing was applied. January 31st, four 
days afterwards, was allowed'to rise and walk by de- 
grees, more and more each day, until February 25th, 
thirty-eight days after the accident; when the ap- 



OR STARCH BANDAGE. 285 

paratus was removed. The limb was perfectly 
straight, firm, and strong enough to permit him to 
walk upon it. In this instance the apparatus was 
not touched until the sixth day after its application, 
when on his complaining of its tightness over the 
instep, the foot was soaked for a few minutes in hot 
water, and, by introducing a spatula under the band- 
age, it was raised sufficiently to free the point of 
pain. Being then allowed to harden, he suffered no 
inconvenience afterwards. 

The next three cases were fractures of the thigh, 
in which, as there was but the one bone to act on, 
and other objects to be considered besides the mere 
support of the fractured ends, it was applied at a 
more advanced stage of the treatment. 

Case Fourth. — Oblique fracture of the middle of 
the femur, 

Francis McG , set. 22 years, of good habits, 

fell, on the 23d of November, down the hatchway of 
a vessel, and fractured his clavicle and femur. The 
clavicle was dressed with the usual apparatus, and 
the femur treated by the long fracture-box, fastened 
on the double-inclined plane, until January 14th, 
fifty-three days after the injury ; when the union not 
being firm, although there was considerable bony de- 
position, the apparatus was applied as follows: — A 
roller was carried smoothly from the toes up to the 
groin, the limb being held up and extended by assist- 
ants; this was starched as in the first case, and 
covered by a second roller. A long splint of binder's 
board was then applied, from the tuberosity of the 
ischium to below the knee, on the back part of the 
thigh, and another from the groin to the patella, in 
front, so as to surround the limb entirely, except for 
the space mentioned in the dressings of the leg. 
These were then covered in the same manner as the 



286 IMMOVABLE APPARATUS, 

splints in the first case, and a simple roller applied 
from the toes up to the lower part of the knee, so 
that it could be renewed at pleasure. The limb was 
now laid on a simple-inclined plane, until the appara- 
tus dried. Five days were necessary to dry it, when 
the man was allowed to walk about ; the limb being 
supported by the sling before mentioned, and the 
splint behind preventing all flexion at the knee. On 
the 2d of February, about ten weeks after the acci- 
dent, the apparatus was removed, without there being 
found any deformity or perceptible shortening in his 
gait ; the measurement showing it to be but little 
more than a quarter of an inch less than the sound 
limb; and on the 7th of February the patient left 
the hospital. 

Cases Fifth and Sixth. — Oblique fractures of the 
upper third of the femur. 

Thomas H , set. 26, a labourer, fractured his 

thigh at its upper third, December 6th, about fifty 
miles from town. He was dressed in the neighbour- 
hood, and did not arrive at the hospital till the third 
day after the accident, owing to the destruction of 
part of the railroad. The limb was much inflamed 
and swollen, and was treated at first by the inclined 
fracture-box, (Fig. 156), lotions, &c, until January 
6th, when the starch apparatus was applied to it, and 
dried in the same manner as in the preceding case. 
On the 14th of January the man was allowed to walk 
about, and the apparatus remained untouched till 
its removal, February 12th, there being perfect 
union and only one-eighth of an inch shorten- 
ing by close measurement, and none perceptible 
in his gait. On the 21st of February, eleven weeks 
after the injury, he was discharged. 

The same apparatus was applied to Patrick 
E (who was admitted February 6th, with an 



OR STARCH BANDAGE. 287 

oblique fracture, caused by blasting), on the 19th of 
February, thirteen days after the accident, and en- 
abled him to sit up in bed five days afterwards, and 
on February 25th, to walk the length of the room. 
On his standing up, he felt too weak to walk readily, 
but had every prospect of doing so shortly. At the 
time he complained of no inconvenience from the 
dressing, and was able to turn about in his bed ; the 
limb being but little shortened by measurement over 
the splints. 

This case got well, but with marked deformity; so 
much so, as to make me resolve never again to ap- 
ply this dressing to the thigh before there was par- 
tial consolidation of the fracture. 

The advantages claimed for this apparatus are, 
that in the case of fractures of the leg it enables 
the patient to sit up, or move about, in fifteen days 
with perfect safety. But I have never deemed it 
expedient to apply it as early as M. Velpeau has 
done, owing to the severe contusions which compli- 
cated most of the fractures which entered the hospi- 
tal at that time. With this restriction, however, it 
might, so far as is proved by the experience of these 
cases, be used in all simple fractures of the leg, as 
few will be found, in private practice, more severe 
than those on which it was tried. 

In hospital practice it promises to be of great 
utility, by doing away the risk of sloughs on the 
sacrum, from the pressure consequent on the long 
confinement to the back; whilst it adds very mate- 
rially to the patient's comfort by allowing him to 
rise to a window, or to go from one apartment to 
another. In case second, it enabled the man to rise 
and undergo an operation for cataract, in a place 
where the light was better than in his own room. 

Since my residence in the Pennsylvania Hospital, 
I have frequently seen it employed by M. Velpeau, 
in his own wards, as well as by other distinguished 



288 IMMOVABLE APPARATUS, ETC. 

French surgeons, and do not hesitate, after twelve 
years observation, to repeat the assurance of its 
utility in such cases of fracture of the leg as have 
been mentioned. 

But I doubt the propriety of its use in fractures 
of the femur, before there is considerable consolida- 
tion, not only from my personal experience, but also 
from a careful investigation of its results in European 
hospitals. To patients possessed of sufficient intelli- 
gence and prudence to understand the necessity of 
caution in moving about it will prove a great com- 
fort, as I should not object to their sitting up with 
the limb supported, as soon as the apparatus had 
thoroughly hardened. In the case of a lawyer, with 
a fracture of both bones of the leg, to whom I applied 
it at the commencement of the third week, it afforded 
great relief, as he was enabled to sit at a table and 
write, as well as attend to his office business. Its 
success in any case will, however, depend on the 
proper application of the bandages ; without skill in 
this operation the effects will, doubtless, prove unfor- 
tunate. 



PART FOURTH. 



CHAPTER I. 

OF THE APPARATUS FOR THE TREATMENT OF DIS- 
LOCATIONS. 

GENERAL CONSIDERATIONS. 

As dislocations, like all affections of the joints, in- 
volve very materially the usefulness of the limb, their 
proper treatment, and consequently the diagnosis of 
the accident, become a matter of equal importance 
with that of fractures. Indeed, as the structure con- 
cerned is much more complicated than that of the 
mere bony tissue, it is questionable whether the 
reputation of a practitioner is not more involved in 
these cases than in the previous class of accidents. 

It would, however, be foreign to my present object 
to consider such injuries at length, and I can, there- 
fore, do little more than hint at the principles in- 
volved, and the means required for their treatment. 

Like fractures, these accidents are mainly de- 
pendent, for a successful termination, on the anato- 
mical knowledge of the surgeon, though often re- 
quiring caution, and a high grade of professional skill, 
in consequence of the peculiar liability of the structure 
involved to take on inflammation, when instant resort 
must be had to means generally included under the 
province of medicine ; in other words, they require 
the skill of a physician and surgeon combined, 
25 



290 APPARATUS FOR DISLOCATIONS. 

Lined by a synovial membrane, strengthened by 
fibrous tissue, surrounded by muscles, and often at- 
tended by important nerves and bloodvessels, the 
effects of a high degree of inflammation in joints 
is nearly always destructive to the tissue concerned ; 
so much so, that it is by no means uncommon for old 
unreduced dislocations to convert the parts around 
them into bone itself, thus completely modifying the 
action of the limb. This tendency should, therefore, 
be borne in mind by the practitioner. 

But even in making an attempt at reduction there 
is something more than mere anatomical knowledge 
requisite to overcome the difliculty; because the dis- 
tance between the origins and insertions of certain 
muscles being materially changed, it follows that some 
of them must be very much stretched, and others re- 
laxed ; and as this stretching results in spasm, relaxa- 
tion of the spasm must be produced before there can be 
any chance of reduction. Here, also, the practitioner 
must combine medicine with surgery, till by means 
of bloodletting, antimonials, &c, the system is placed 
in such a state, that the use of mechanical means 
may enable other muscles to replace the bone in its 
proper situation. 

Again, as a certain amount of muscular paralysis, 
laceration of ligaments, &c, often remains to a greater 
or less extent after the reduction, the use of counter- 
agents in the after-treatment is equally important ; 
lest there be a recurrence of the accident. 

These points, however, I can merely hint at, and 
must refer those desirous of a more thorough inves- 
tigation of the pathology and diagnosis to larger 
works ; merely giving here such points of practice as 
may serve the young practitioner for the moment. 



CHAPTER II. 

ON DISLOCATIONS OF THE HEAD AND TEUNK. 

The general principles involved in the treatment of 
this class of injuries being those just stated, I pass 
immediately to the consideration of the means re- 
quired in the special cases. 

DISLOCATION OF THE LOWER JAW- 

This, whether on one or both sides, requires that 
the condyle should be freed from the projections of 
the anterior portions of the glenoid cavity of the 
temporal bone, see Fig. 178. 

Fig. 178. 




Reduction. — To accomplish the reduction, seat the 
patient on a low chair, and let his head be supported 
against the breast of an assistant ; whilst the surgeon, 



292 DISLOCATIONS OF THE 

introducing his thumbs within the mouth, places them 
upon the molar teeth, and his fingers beneath the 
chin, so that he may depress the posterior portion 
of the jaw by the pressure of his thumbs, elevate 
the chin by that of his fingers, and by freeing the 
condyles from bony prominences enable the mus- 
cles to draw the bone into its place. But as 
they frequently do this with great violence, and 
are apt to pinch the fingers very severely, the sur- 
geon should slip his thumbs off the teeth to the out- 
side of the gums, as soon as he finds the jaw begin 
to yield to his movements ; or wrap them well before 
introducing them into the mouth; or direct an assist- 
ant to place a fork-handle or plug of wood between 
the teeth of the patient, in order to save himself from 
injury. 

After-treatment. — The after-treatment consists in 
the application of any of the bandages before referred 
to under the head of Fractures of the Jaw ; in keep- 
ing the patient on soft food for several days after the 
reduction, and in directing him to avoid biting hard 
substances for some weeks subsequent to the accident, 
lest it again occur. Should inflammation of the joint 
supervene, it must be counteracted by the antiphlo- 
gistic treatment. 

DISLOCATIONS OF THE OBLIQUE PROCESSES OF THE 
VERTEBRA 

Are so liable to produce death by pressing upon the 
spinal cord, especially in those of the neck, that it 
is better, as a general rule, to permit the deformity 
to exist, rather than endanger the life of the patient 
by attempting its reduction. 

DISLOCATIONS OF THE RIBS 

Are said to occur at their posterior and anterior ex- 
tremities, although many authors doubt the possibility 
of the first, without its being accompanied by frac- 



HEAD AND TRUNK. 



293 



ture. In either case, the bandage directed for the 
treatment of fractures of the ribs will be as much as 
we can employ for their reduction ; the compresses 
being placed over the dislocated extremity, in order 
more effectually to retain it in its natural position. 

DISLOCATIONS OF THE CLAVICLE 

May occur either at its sternal or humeral extremity. 
The Sternal end may be dislocated, either forwards, 
backwards, or upwards ; and requires that the shoulder 
should be carried in the opposite direction to that in 
which the sternal extremity rests, whilst the bone is 
at the same time drawn off from the sternum, by using 
the humerus as a lever, on the same principles as 

Fig. 179. 




those laid down by Dessault, in his bandage for the 
reduction of a fracture of the bone. 

Reduction. — The patient being seated a on low 

25* 



294 DISLOCATIONS OF THE HEAD AND TRUNK. 

chair or stool, the surgeon should stand at his side, 
and placing his foot on the chair, with his knee in the 
axilla, bend the arm over his knee as a fulcrum with 
one hand, and with the other force the shoulder for- 
wards, backwards, or upwards, according to the posi- 
tion of the dislocated sternal extremity (See Fig. 
179). 

After-treatment. — This consists in the use of Fox's 
sling, or the 2d and 3d roller of Dessault, for some 
two or three weeks. 

DISLOCATIONS OF THE HUMERAL EXTREMITY OF THE 
CLAVICLE 

May be either above, or beneath the acromion pro- 
cess of the scapula, and is easily reduced when the 
shoulder is drawn outwards, by acting on the humerus 
as a lever. But though the reduction is easy the 
after-treatment will be found very difficult, in conse- 
quence of the small articulating faces concerned 
giving rise to a constant recurrence of the injury. 
The only means that I have found certain for the 
retention of the bone in its position, after the reduc- 
tion, is the Spica Bandage of the Shoulder (Fig. 53), 
with a large compress directly over the acromion, 
and the use of a sling to the elbow, to keep up the 
head of the humerus. 



CHAPTER III. 

ON DISLOCATIONS OF THE UPPER EXTREMITY. 
DISLOCATIONS OF THE HEAD OF THE HUMERUS. 

These usually occur in three directions ; either into 
the axilla; under the pectoral muscle; or on the 
dorsum of the scapula; and require, as a general 
rule, the application of the extending force in the 
line that the limb naturally takes whilst dislocated. 
Thus, if the head of the bone is in the axilla, draw 
the arm in the line of the body ; if under the pectoral 
muscle, off from the body ; if on the dorsum scapulse, 
across the chest ; or elevate it so as to throw the head 
of the humerus into the axilla, and then draw parallel 
with the body. There is, however, some difference 
in the amount of force required, and the means of 
applying it, according as the case is recent or old, 
in a strong muscular patient, or in one of less power 
and more delicate frame. 

Reduction. — The simplest means, and generally 
applicable only to cases of very recent occurrence, or 
of but slight muscular development, are those repre- 
sented in Fig. 179, and just spoken of under disloca- 
tions of the clavicle. The cut explains itself. 

The next plan is, for the surgeon to place the heel 
of his foot (without his shoe) in the axilla of the pa- 
tient, in order to make counter-extension, and then 
draw upon the arm by seizing the patient's wrist, or 
by grasping a towel fastened to the wrist or the lower 
end of the humerus, as represented in Fig. 180. If 
his own strength is not sufficient, assistants may lay 
hold of the towel, behind the hands of the surgeon, 
and assist the extension. But should the patient be 



296 



DISLOCATIONS OF THE 



muscular, a solution of tart, emet., 



or such other 
means as will induce faintness and muscular debility, 
will also probably be required. 

Fig. 180. 




In old luxations, or in well-developed subjects, 
even greater force than this may be necessary, such 
as the application of pullies to the humerus, and the 
use of more powerful means of making counter-ex- 
tension on the scapula. Indeed, where pullies are 
at hand, the surgeon will often save himself much 
hard work, by employing them in the first instance. 
In order to use them, attach the towel or band to the 
lower portion of the humerus, by means of a clove- 
hitch (as shown hereafter), and fastening the hook of 
the pulley in the other end of the towel, place a 
sheet or padded strap around the scapula, as repre- 
sented in Fig. 181. The extension may then be 
made either in the position exhibited in that cut, or 
with the patient lieing down, as in Fig. 180. In the 
application of these means of reduction much will 
depend upon the scapula being firmly fixed ; and where 
the padded strap cannot be had, a narrow band should 



UPPER EXTREMITY. 



297 



be applied to the acromion scapulae, in addition to 
the sheet used to fix its lower portion. As the axil- 
lary vessels and nerves are apt to be acted on by the 
force employed to reduce the bone, their position 
and the possibility of their adhesion to the head of 
the humerus, especially in old dislocations, should 
always be borne in mind. (See Gibson's Surgery.) 

Fig. 181. 




After-treatment. — Keep the head of the humerus 
perfectly at rest, by means of a sling, for three or 
four weeks, until the laceration of the capsular liga- 
ment has united, and combat the subsequent inflam- 
mation by leeches, &c, when required; cautioning 
the patient against elevating the arm for many weeks 
after the accident, lest he reproduce the injury. 

DISLOCATIONS OF THE FOREARM 

May be divided into those of both bones, forwards or 



298 



DISLOCATIONS OF THE 



backwards, and into dislocations of the head of the 
radius alone. 

As the first dislocation, viz., both bones forwards, 
requires the fracture of the olecranon, the treatment 
should be the same as that directed for this injury. 
In the dislocation of both bones backwards, the ole- 
cranon, resting on the posterior surface of the lower 
portion of the humerus (Fig. 182), requires that suf- 

Fig. 182. 




ficient. flexion be made to bring it down into the sig- 
moid cavity of the humerus, and free the head of the 
radius from the condyles. 

Reduction. — To accomplish this, let an assistant 
make counter-extension by seizing the middle of the 
arm, whilst the surgeon makes extension at the wrist ; 
or let him put his knee in the bend of the arm, and flex 
the forearm upon it; or bend it around a bed-post, 
or upon the hands of assistants. 

After-treatment. — Apply a roller from the 
fingers up to the middle of the arm, and dress 
the limb with an angular splint, as directed for 
fractures of the condyles ; making passive motion 
every three or four days, to guard against anchy- 
losis. 



DISLOCATION OF THE HEAD OF THE RADIUS 

May also be either forwards or backwards, producing 
either fixed pronation, or supination of the hand. 



UPPER EXTREMITY. 299 

Reduction. — When dislocated backwards, as is 
most commonly the case, the hand being strongly 
pronated, should be raised by the surgeon and forci 
bly supinated with one hand, whilst with the other 
he presses the dislocated extremity from behind for- 
wards, assisting this movement by slight flexion of 
the elbow. If extension and counter-extension are 
required, an assistant should make counter-extension 
by seizing the arm, whilst extension is made at the 
wrist by the surgeon, who also forces it into supina- 
tion. If dislocated forwards, the manipulations of 
the surgeon are of course to be reversed. 

After-treatment. — Place the arm in a sling, or on 
an angular splint, and keep it at rest; combating 
inflammation, and also any tendency to anchylosis. 

DIAGNOSIS OF INJURIES OF THE ELBOW. 

Although the Elbow-joint is comparatively super- 
ficial, and the prominences of the different bones com- 
posing it sufficiently evident in its natural state, yet 
is it among the most difficult of the joints in which 
to diagnosticate an injury, in consequence of the 
swelling which so rapidly ensues. Fractures of the 

Fig. 183. 




condyles of the humerus ; fracture of the olecranon 
process of the ulna ; dislocations of different kinds, 
and simple contusions, have all not unfrequently been 
thought by different surgeons to exist in the same 



300 DISLOCATIONS OF THE 

case. A simple rule, which I learned under Vel- 
peau, and the accuracy of which I have frequently 
tested in the diagnosis of these injuries, is the fol- 
lowing : Carry a string in a circle, round the elbow, 
from the external to the internal condyle, and when 
the forearm is semiflexed it will include the olecranon 
process and the two condyles, in the normal state ; 
whilst the removal of either of these points out of 
the circle will show the displacement consequent upon 
the injury, as in Fig. 183, where, owing to dislocation 
of the forearm backwards, the olecranon is above the 
line referred to. 

DISLOCATIONS OF THE BONES OF THE FOREARM ON THE 
WRIST 

Are usually reduced by the application of force to 
the front or back of the forearm, according to the 
dislocation. But as the laceration of the ligaments 
here involves a joint peculiarly liable to disease, per- 
fect rest for several weeks, strict antiphlogistic reme- 
dies, &c, should be insisted on; particular attention 
being given to guard against anchylosis. The fre- 
quency of fracture of the lower end of the radius, 
and the liability to mistake it for a dislocation of this 
part, should also be borne in mind. (See Barton's 
Fracture of Lower End of Radius, p. 229.) 

DISLOCATIONS OF ALL THE BONES OF THE WRIST 

Are seldom seen, except when complicated with such 
severe injuries of the soft parts as may require ampu- 
tation of the limb. But the Magnum alone may be 
forced out of the cavity formed by the scaphoides 
and lunare, so as to project on the back of the joint. 

Reduction. — Press firmly on the head of the 
magnum. 

After-treatment. — Apply a compress over the bone, 
and bind the hand firmly to a splint applied on its 
palmar surface, extending it up to the arm, so as to 



UPPER EXTREMITY. 301 

keep the part at rest until the ligaments are united, 
or strengthened. 

DISLOCATIONS OF THE METACARPAL BONES 

Are very seldom seen, except in that of the thumb ; 
the treatment of which may be included in the con- 
sideration of 

DISLOCATIONS OF THE PHALANGES. 

These may be either on the metacarpal bones, or 
on each other. I shall, however, take the dislocation 
of the first phalanx of the thumb, upon the meta- 
carpal bone, as indicating the treatment of all these 
cases. 

Reduction. — The phalanges being too short to 
enable any one to hold them firmly, the surgeon should 
first surround the bone with a piece of buckskin, and 
apply over this a piece of tape tied in a clove-hitch. 

Fig. 184. 



Then seizing the tape, make extension, pulling gra- 
dually downwards, so that the extremity of the pha- 
lanx may describe the arc of a circle, and thus free 
its upper portion from the projecting metacarpal bone ; 
counter-extension being made by assistants at the 
wrist or forearm, if required. Should the difficulty 
of the reduction seem to be owing to the tension of 
the lateral ligaments, the internal one may be divided 
26 



302 DISLOCATIONS OF THE 

by introducing a narrow, sharp-pointed knife or 
needle, and dividing it by a sub-cutaneous incision. 

After-treatment. — As in fractures of the pha- 
langes. 

THE CLOVE-HITCH, 

Just referred to, offers one of the most certain means 
with which I am acquainted, of applying an extend- 
ing force to a limb, and is, I think, far preferable to 
the wet rollers, and other means of fastening the ex- 
tending bands so commonly recommended. In dis- 
locations of the humerus, or thigh, it will be found 
especially useful, and in my experience has never 
slipped when once properly applied. Though long 
recommended for the thumb, my attention was first 
called to its application to other parts, by a sailor in 
the Pennsylvania Hospital, in 1837, with a dislocated 
hip, who, seeing all the usual means of fastening the 
extending band slip and fail, just as the bone was 
nearly reduced, suggested that he should be allowed 
to tie the sheet himself, which he did in a clove-hitch, 

Fig. 185. 




so that it held firmly and relieved him of his injury. 
Since that time I have employed it, and seen it em- 
ployed, in numerous cases without its slipping ; and 



UPPER EXTREMITY. 303 

have always been pleased with the result. Sanc- 
tioned, as it now is, by Mr. Fergusson, it will pro- 
bably supplant the miserable means of the towel and 
wet roller, and thus save a great expenditure of time 
and trouble. 

To make it, practice with a piece of twine until 
the turns are learned, as follows : — Turn the string 
from right to left so as to form a circle, and bring 
one portion of the cord in front of the other, as in 
the right hand turn of Fig. 185. Then make a second 
turn of another portion of the twine, and twist it so 
as to place it behind the first turn, as in the left hand 
portion of the figure. On drawing the ends, the 
loops will be tied so tight, that the cord will break 
before the knot will slip. After learning these turns 
of the knot with twine, no difficulty will be expe- 
rienced in making it with a sheet, or towel, in various 
other ways. 



CHAPTER IV. 

ON DISLOCATIONS OF THE LOWER EXTREMITY. 
DISLOCATIONS OF THE HIP-JOINT 

Neakly always throw the head of the femur out of 
the acetabulum, into some unnatural position upon the 
innominatum. As the sides of the acetabulum pro- 
ject considerably above the surface of the ilium, it is 
requisite that, in addition to the usual extending and 
counter-extending bands, a lateral band should be 
applied on the inside of the thigh, near its upper 
third, in order to draw the femur off from the pelvis, 
and free the head of the bone from the acetabular 
prominences. This band has not been represented 
in the cuts, owing to the difficulty of doing so without 
confusing the drawings, in the works from which they 
have been copied; but its action is so simple that I 
think it cannot be misunderstood. 

As the means employed for the reduction of the 
four different dislocations of this bone vary only in 
regard to the line of extension (which, it should be 
recollected, is generally to be made in the line which 
the dislocated bone naturally takes), I shall confine 
my description to the dislocation upwards on the 
dorsum of the ilium, as the most common. The pul- 
lies being required in most cases of dislocation of the 
femur, and as even with these the reduction is a matter 
of considerable difficulty, it will save much useless 
expenditure of strength on the part of the surgeon 
to apply them at once, without attempting other 
means. But where pullies cannot be obtained, the 
plan of Dr. Fahnestock, of Pittsburgh, reported by 



DISLOCATIONS, ETC. 305 

Prof. Gilbert, 1 of using the power furnished by 
twisted rope, will be found to form an excellent sub- 
stitute. 

The mode of application is as follows : "Place the 
patient and adjust the extending and counter-extend- 
ing bands, as for the pulleys ; then procure an ordi- 
nary bed-cord, or wash-line, tie the ends together 
and again double it up on itself; then pass it through 
the extending tapes or towel, doubling the whole once 
more, and fasten the distal end, consisting of four 
loops of ropes, to a window-sill or staple^ so that the 
ropes are drawn moderately tight; finally, pass a 
stick throughout the centre of the doubled rope, 
dividing the strands equally by it. Then revolving 

Fig. 186. 




the stick as an axis or double lever, the power is pro- 
duced exactly as it should be in such cases ; namely, 
slowly, steadily, and continuously; which, with the 
aid furnished by the surgeon to the immediate seat 
of lesion, and to the system in general, cannot fail 
to conduct the case to a happy issue." The cut shows 
fully the manner of its application. 

But when it is proposed to employ pullies, proceed 
as follows, to the 

Reduction. — Fasten a roller-towel, or sheet, upon 

1 Amer. Journal Med. Sciences, No. viii., April, 1845. 

26* 



306 DISLOCATIONS OF THE 

the lower end of the femur by a clove-hitch. Attach 
the pullies to the free ends of the towel, and fasten 
the hook of their opposite extremity to a staple, bar, 
or other fixed point. Place a sheet thickly folded 
in the perineum of the sound side, to make counter- 
extension ; another across the pelvis from the ilium 
of the injured side, and a strong towel on the inside 
of the injured thigh, in order to draw the head of the 
femur off from the pelvis. Then, seeing that the 
bands are firmly fixed, and the patient's system re- 
laxed by constitutional means, direct the assistants 
to pull slowly but steadily on the pullies, until the 
counter-extending . band and the transverse pelvic 
band become quite tense and the muscles begin to 
yield to the power acting on them. Then the sur- 

Fig. 187. 




geon, seizing the leg by the ankle, should use it as a 
lever, to produce rotation of the head of the femur, 
and directing another assistant to draw strongly upon 
the towel which is on the inside of the thigh, continue 
the use of these different forces until the parts seem 
relaxed ; when, ordering the extension to cease, sud- 
denly the bone will be drawn into its socket. Should 
the muscle, however, not do so, a repetition of the same 
means will frequently succeed, although at first they 
failed. 

After-treatment. — Tie the thighs together, and keep 
them at perfect rest; combatting any inflammatory 
symptoms that may arise. 



LOWER EXTREMITY. 



307 



The line of direction of the extending force in the 
other dislocations of the femur will be evident from 
the following cuts : 

Fig. 188. 




In the Dislocation on the Pubis the limb is to 
be carried off from the body and placed as in Fig. 
188, with the addition of the towel to the inside of 
the thigh. 

In the Dislocation into the Sciatic Notch the 
limb should be carried in the opposite direction, that 
is, over the sound limb, and rotation practised by 
acting on the leg. The inside femoral towel is not 
required here, see Fig. 189. 



Fig. 189. 




Various other means and modifications have been 
recommended for the reduction of these dislocations, 
but those just referred to will, I think, be found 
sufficient in most cases, whilst they have the sane- 



308 



DISLOCATIONS OF THE 



tion of some of the highest authorities in the profes- 
sion. 

In the Dislocation into the Fokamen Thykoi- 
deum the application of the extending force, as repre- 

Fig. 190. 




sented in Fig. 190, has advantages, in some cases, 
especially as directed by Sir. A. Cooper. The prin- 
ciple of its action may be seen at a glance, and is 
mainly useful in facilitating rotation of the head of 
the bone. 



DISLOCATION OF THE PATELLA 

Can only occur laterally, unless there is also lacera- 



LOWER EXTREMITY. 309 

tion of the quadratus femoris, or ligamentum pa- 
tellae. 

Reduction. — In the lateral dislocation, the surgeon 
should place the heel of the patient on his shoulder, 
and pressing with his fingers on the edge of the 
patella, force it inwards or outwards, according to 
the character of the accident. 

After-treatment. — Keep the limb extended for a 
few days, and direct the patient to wear a knee-cap 
or bandage (Fig. 91) for some weeks afterwards. 

DISLOCATIONS OF THE HEAD OF THE TIBIA 

May occur in either of four directions ; forwards, 
backwards, inwards, and outwards. In either case 
we should proceed as follows : 

Reduction. — Extension being made by the hands 
of assistants at the lower part of the leg, and counter- 
extension at the inferior portion of the thigh, the 
surgeon should seize the condyles of the femur with 
one hand, and the head of the tibia with the other, 
and press them in opposite directions, as soon as he 
judges that sufficient extension has been made to 
enable the bones to take their natural position. 

After-treatment. — Keep the limb extended, and 
combat the inflammation of the joint, which is 
usually very great. The use of a splint, bandages, 
&c, may be required for some time, in order to 
insure perfect rest and keep down inflammation. 

DISLOCATIONS OF THE FIBULA, 

At either extremity, are so rare, except when accom- 
panied by fracture, that I have little to say about 
them. When the luxation of the lower portion of 
this bone is accompanied with fracture of the tibia, 
it will require considerable skill to enable the sur- 
geon to save the ankle-joint. 

DISLOCATIONS OF THE BONES OF THE TARSUS, 

Like those of the carpus, are generally the result of 



310 DISLOCATIONS, ETC. 

such violence as implicates very seriously the soft 
parts, inducing such violent inflammation as requires 
the greatest care, to avoid the necessity of amputa- 
tion. Their treatment, consequently, could not be 
properly considered here, and the reader is therefore 
referred for it to the books on Surgery. 

DISLOCATIONS OF THE METATARSAL BONES AND 
PHALANGES 

Resemble very closely the same injury to the bones 
of the hand, and should be treated accordingly. See 
page 301. 

But it must be recollected that if the joint of a 
toe remains unreduced, the pressure of the boot 
upon the projecting point will be liable to keep up a 
constant ulceration, and that this has sometimes 
been so troublesome as to induce the patient to sub- 
mit to amputation rather than endure it. 



PART FIFTH 



MINOR SURGICAL OPERATIONS. 

The diversity of opinion which exists in relation to the 
number and character of the operations which should 
be classed under the above head, renders the limits 
of this portion of the subject optional with those 
who may choose to classify them. I shall, therefore, 
in the subsequent pages, treat of such operative 
measures as every physician is liable to be called on 
to practice, and especially of those which fall 
to the lot of Residents of Hospitals and Junior 
Practitioners. 

As a class, the Minor Operations are generally of 
the simpler kind, endangering the life of the patient 
only in consequence of the existence of some extra- 
ordinary circumstance ; as surgeons also usually 
regard them of comparatively little importance, they 
may be correctly designated as minor operations, 
in comparison with those of a higher grade. But 
lest an incorrect estimate of their value be formed 
from their name, it should always be recollected that 
the term used is a comparative one. As preliminary 
measures, or as adjuvants to more important opera- 
tive means, some of these operations possess an im- 
portance that cannot be overlooked ; whilst a proper 
performance of them will often remove the neces- 
sity of resorting to more severe measures. In pro- 
portion, also, to the apparent simplicity of these 



312 MINOR SURGICAL OPERATIONS. 

duties is the professional injury likely to result to 
the practitioner who fails to execute them with suc- 
cess ; and more than one surgeon of high operative 
skill has now to lament injuries produced by himself 
in the apparently simple operation of venesection. 



CHAPTER I. 

OF THE DUTIES OF ASSISTANTS IN OPERATIONS. 

The number of Surgeons to be found in any district 
not embracing a city being generally limited, it fol- 
lows that in most instances when one is called on to 
operate, he must look to his brother practitioners for 
assistance. Every physician should, therefore, if 
only from philanthropic motives, endeavour to qualify 
himself for the performance of such offices; and the 
duties of assistants, under these circumstances, may 
therefore justly be placed at the head of the Minor 
Operations. 

To act as an Assistant to the greatest advantage, 
it is requisite that the general object of the opera- 
tion, as well as the peculiar views of the operator, 
should be thoroughly understood previous to its com- 
mencement. Every medical man will, of course, 
possess a knowledge of the first ; but if time,' or want 
of practice, has impaired his recollection of the de- 
tails of his surgical studies, he should never hesitate 
to request the operator to designate the steps of the 
operation, and also to specify particularly, any pecu- 
liarities that are likely to arise in its progress. The 
object of each operation being usually of a definite 
character, it is not easy to lay down such rules as 
will be invariably applicable ; yet as there are many 
points in which all operations are alike, I shall en- 
deavour to systematize the duties of assistants at all 
operations, and then to specify them in a few of those 
of most importance ; believing that their observance 
will add to the comfort of all concerned. 

1st. Every Assistant should endeavour so to identify 
27 



314 OF THE DUTTES OF 

himself with the operator, as to act solely under his . 
will. This, of course, requires a full explanation on 
the part of the operator of his views, &c, previous 
to the operation. 

2d. Each assistant should learn what are his own 
peculiar duties, and confine himself solely to them. 

When each assistant is thus arranged there can be 
no confusion. Should an accident occur, the quiet 
of the assistants, and their attention to their own 
duties, until called on by the surgeon to do some- 
thing else, will then aid very materially in combat- 
ting it : and if this sort of discipline was more gene- 
rally observed at all operations, it would prove highly 
serviceable. When each man is at his post every 
duty can be well and quickly performed ; whereas, 
when each one endeavours to do everything himself, 
all are apt to add to the confusion. 

3d. Each assistant should, in every case, remember 
that the responsibility of the operation rests with 
the operator alone, even although the patient may 
have previously been under his special care. 

4th. Every assistant should preserve silence, and 
never make a suggestion as to the operation after 
the first incision, unless directly inquired of by the 
operator. With a good surgeon such a rule would 
be useless ; but occasionally the superior knowledge 
of an assistant may tempt him to violate it. In 
all operations with a good surgeon, every assistant 
will feel that he is a necessary part of the scene, the 
events of which, though calmly directed by the opera- 
tor, could not be thus managed without his assistance ; 
but with an ignorant one he is of yet greater conse- 
quence. Let the assistant, therefore, understand cor- 
rectly the importance of his position under all cir- 
cumstances, and endeavour to realize, that the suc- 
cess of every movement depends on proper indi- 
vidual effort. As the limbs to the head, so are as- 
sistants to the surgeon ; remove either and the value 
of each is impaired. 



ASSISTANTS IN OPERATIONS. 315 

In order to illustrate more directly the importance 
of the part often played by the assistant in opera- 
tions, and the effect upon the operation itself, I 
would mention two, out of many of the cases that 
could be cited on the same point. 

In the one, a distinguished French surgeon was 
extracting a cataract, and after lacerating the cap- 
sule of the lens, raised the flap of the cornea to per- 
mits its escape, when he received in his hand the 
whole contents of the eye-ball, solely because of the 
ignorance of his assistant as to his duty in holding 
the upper lid. In the other case, an operation for 
lithotomy was delayed many minutes after the peri- 
neum Was cut, simply in consequence of the assist- 
ants not knowing how to hold the patients limbs ; the 
operator being compelled to stop and show them 
how to do it. Not only the comfort, but also the 
safety of the patient, therefore, will often- be found to 
rest on the observance of these or similar rules ; and 
attention to them consequently becomes a matter of 
serious importance to all parties. 

But in order to enable an assistant to act his part 
well, it is necessary that he should have more than 
general rules to guide him ; and the consideration of 
his duties in a few special operations will not now 
be foreign to the subject. I shall, therefore, briefly 
detail the duties of assistants in some of the capital 
operations, even at the risk of trenching on operative 
surgery. 

Before proceeding with any severe operation some 
means should be employed to mitigate its pain ; and 
as public attention has now been given, for many 
months, to the use of Anaesthetics, a reference to 
them is necessary. In my opinion, their employ- 
ment should be the first act of the assistants in 
every operation of a very painful character, except 
those connected with the mouth and throat. I am 
well aware that on this point there is some diversity 



316 OF THE DUTIES OF 

of sentiment, and that some good old-fashioned sur- 
geons, like the opponents of Jenner, have strong pre- 
judices against their use. Having, however, em- 
ployed them in a very large number of cases, and 
fully satisfied myself of their utility, I am perfectly 
willing to rely upon my own observations, and to 
recommend their administration to the reader of 
these pages as a measure which should be regarded 
by all as one of a high moral obligation, on the 
ground that the diminution of human suffering is 
the highest point of the surgeon's duty. At a very 
early period after its introduction to public notice, 
I administered Ether to the cases treated before the 
medical classes of the University of Pennsylvania, in 
the clinical lectures of that institution ; and I have since 
continued to employ it, both publicly and privately, 
without having encountered any inconvenience of a 
serious character. Chloroform I soon found was a more 
dangerous article, and in one instance was compelled 
to resort to active measures to prevent a congestion 
of the brain. For this and other reasons I have long 
had doubts of its safety. But a mixture of chloroform 
and ether, in the proportion of one part of chloro- 
form to four of ether, or one to three, as recom- 
mended by Professor W. Atlee of this city, has 
always proved in my hands a most pleasant agent. 
The stimulus of the ether, and the extreme seda- 
tion of the chloroform, seem in this compound to 
be happily counteracted, and it is this combination 
that I now exclusively employ. To the practitioner 
who has never administered Ether there is yet a por- 
tion of his education to complete ; and as its effects 
when first given might induce him to mistake its 
true value, or an incorrect administration mislead 
him in its application, I shall describe the steps 
usually taken, and their results upon the economy, 
by condensing a portion of the excellent account of 



ASSISTANTS IN OPERATIONS. 



317 



Dr. Warren, of Boston. 1 To those who have not em- 
ployed Anaesthetic agents, a reference to the treatise 
of this distinguished surgeon will furnish an amount of 
details, both as to their administration and physiolo- 
gical effects, that cannot but prove most useful. 

The appearances presented by patients under the 
influence of ether have a general resemblance, varied, 
however, by the constitution of the patient and mode 
of application. The mode of application is very 
varied ; a towel folded into the shape of a funnel, or a 
hollow piece of sponge, answer tolerably well, but 
cause a great waste of ether, by permitting its escape 
into the atmosphere. A tube of any kind contain- 
ing a sponge answers better ; such, for example, as 
the ordinary argand lamp chimney-glass, or a some- 
what similar tube of tin, either being large enough 
to surround the lips. 

A very simple apparatus that any tin-plater can 
manufacture, is one that I have had made for my own 
use. The shape will be readily understood by refer- 
ence to Fig. 191. It is a conical tin tube, cut out so 

Fig. 191. 




as to receive a portion of the chin and nose. Its 

1 Etherization, with Surgical Remarks, by John C. Warren, 
M.D. Boston, 1848. 

27* 



318 OF THE DUTIES OF 

greatest length, as adapted to an adult, is six and a-half 
inches ; its transverse diameter, at a point correspond- 
ing with the two holes at C, is three and a-quarter 
inches: its antero-posterior diameter is three and 
a-half, and its apex, which is freely perforated to admit 
the air, is a circle of seven- eighths of an inch in diame- 
ter. The portion of the cut at B gives an anterior 
view from above, or of the part adapted to the jaw; 
that at C is a full posterior view of the tube as notched 
to receive the point of the nose. The two holes are 
to facilitate the escape of the breath of the patient, as 
well as to favour the inspiration of atmospheric air. 

(Fig. 192) is a full front view of the instrument as 
apj. lied to the mouth ; the nose being left open or 

Fig. 192. 




closed at the pleasure of the operator. Gene- 
rally it is not necessary to close it, expiration being 
mainly performed through the nostril, and inspiration 
through the tube. Without claiming anything as espe- 
cially meritorious, this instrument, from the facility 
of its manufacture, and the durable character of the 



ASSISTANTS IN OPERATIONS. 319 

material, will be found of service. The sponge or 
towel, if used alone, is apt to irritate the lips by con- 
tact of the ether. The sponge being sunk in the 
tube avoids this, and also prevents a wasteful eva- 
poration. 

But before employing any instrument the pa- 
tient should be shown how to inhale and expire 
through them, without ether, so that when the 
sponge is wet, it may not be to him an entirely new 
operation. The length of time during which inhala- 
tion maybe continued, will vary with the peculiarity 
of the patient. With the mixture of ether and chlo- 
roform, as employed with a tube, I have placed some 
patients under its influence in two minutes ; others 
in five; whilst others, especially if accustomed to the 
free use of spirituous liquors, have required twenty or 
more minutes. When a patient is once well ether- 
ized, the sponge containing the liquid should be re- 
moved entirely from the mouth, and re-applied for 
two or three minutes more, as consciousness returns. 
During tedious operations I have found eight or ten 
re-applications necessary, the patient recovering par- 
tially between each re-application: and generally 
being clamorous for more, if conscious of pain. The 
following effects of inhalation I condense from Dr. 
Warren's work : 

"The first symptom is a short cough (or gasp), 
which impels the patient to remove the sponge or 
tube from his mouth ; but no severe irritation being 
felt, he proceeds to inspire the vaporous draught 
more and more deeply until he becomes insensible. 
The respiration is then often audible, and sometimes 
even (almost) apoplectic; afterwards feeble and 
almost imperceptible ; a state which, however accus- 
tomed to it, leads the surgeon to examine the 
pulse." 

At this moment the patient lies as if dead, and 
may be cut in the most sensitive part of the body, 
without perceiving pain. 



320 OF THE DUTIES OF 

The pulse, says Dr. Warren, "being at first quick- 
ened from mental causes before the operation, is still 
more so a short time after the inhalation of ether, 
sometimes excessively so: subsequently it becomes 
slower, feebler, and even scarcely perceptible. When 
this is found to be the case the sponge should be 
removed, and the pulse will become more free. Then, 
if necessary, the inhalation may be resumed. 

" The face, neck, and upper part of the chest, at first 
become red and flushed, but this soon gives place to 
paleness, succeeded by cold perspiration. 

"Nausea or vomiting occasionally exist, or may be 
prolonged after the inhalation. This I have found 
very rare. 

" The muscular system is often excited at an early 
period, the fists clenched, the muscles of the upper 
extremities and neck contracted ; more commonly they 
perform various movements as if the patient were 
trying to extricate himself from the attendants. This 
is rarely seen in the lower extremities." 

I have frequently seen surgeons who were unac- 
customed to the appearances of etherization, alarmed 
at these muscular demonstrations, cease the inhalation, 
and regard its employment as worse than useless. A 
few minutes perseverance would, in most instances, 
have been followed by perfect repose. 

" The conjunctiva of the eye is often injected with 
blood, the pupils generally contracted, sometimes 
dilated; in a powerful etherization, often fixed. The 
eyelids are occasionally open, more frequently closed; 
although the patient has the power to open them 
when called upon, if still conscious, thus affording a 
test which, though not universal, enables the operator 
to determine when to commence the operation." 

When the assistant administering the ethereal mix- 
ture has brought the patient to this point, viz., appa- 
rent unconsciousness, inability to move the eyelids, 
and with a pulse beginning to act more slowly, he 



ASSISTANTS IN OPERATIONS. 321 

should invite the operator to proceed, and then keep- 
ing is finger on the patient's pulse, re-apply the tube 
as it increases in frequency, or consciousness returns ; 
but not otherwise. 

" The most curious changes are produced by ether- 
ization on the sensitive and intellectual functions, 
but are exceedingly various in their form and order. 
In many, tactile sensation appears to be suspended, 
while the intellect exists. The brain takes cogni- 
zance of external objects, while it either does not 
notice the impressions on the feeling nerves, or if it 
does, they do not produce the usual effect." 

Many singular examples of this have been met with 
by all who have employed ether. A lady to whom 
I administered the chloric ether for the extraction of 
a large tooth, told me positively, when under its in- 
fluence, that she was not at all affected by it ; but 
judging from her pulse that she was, I requested the 
dentist to proceed, and he extracted the tooth in the 
midst of her remonstrances. In three minutes she 
was herself, and declared that though she felt the 
touch of the forceps, and the crush of the extraction, 
it caused her no pain. I once operated for hemor- 
rhoids, on a lady, who quoted King Lear's soliloquy 
during the operation. A man with a bad fissure of 
the anus, which was so sensitive that the little finger 
could not be introduced into the rectum without 
almost creating a convulsion, had the parts freely 
exposed by a rectum speculum, and touched with 
anhydrous potassa. Though conscious of external 
events, he asked, on recovering his consciousness, 
when the operation would commence. But such cases 
are now too numerous to count. 

The duration of the effects of ether vary. Insen- 
sibility may exist for five or ten minutes, but I have 
seldom produced a longer degree without repeating 
the etherization, not having believed it necessary. 
Nervous or hysterical symptoms occasionally super- 



322 OF THE DUTIES OF 

vene in the cases of females, but they usually pass 
off within fifteen or twenty minutes. In most of the 
cases that I have lately noticed, no unpleasant effects, 
of any severity, have lasted over a half hour, the nausea, 
hysterics, &c, formerly noticed, not having followed 
the application of the mixture that I have just referred 
to. With the pure ether I think they are more common. 
But, in every case, simple measures, such as fresh air 
taken into the lungs by a long inspiration, cold spong- 
ing of the face and head, a draught of cold water, or 
the use of smelling salts, have been all that was requi- 
site, the patient frequently recovering, in every re- 
spect, in five or ten minutes, without resort to any- 
thing more than a glass of water. 

With the safety of its administration thus shown, I 
again invite those desirous of a more detailed account 
of anaesthetics, to read Dr. Warren's little volume 
on Etherization, and urge them to try the effects 
of the chloric ether on a fit subject, before allowing 
prejudices and theoretical dangers, or exaggerated 
publications of fatal cases in journals and newspapers, 
to deter them from employing one of the greatest dis- 
coveries of modern times. The fatal cases from ether 
have been extremely doubtful, and were, even as re- 
ported, in its earlier administration. Chloroform, 
alone, is a dangerous article. But I can, with a full 
sense of responsibility, recommend the inhalation of 
about half a fluid ounce of the mixture of chloroform 
and ether, in the proportion of one part of the first 
to four of the second, employed in such an inhaler 
as will prevent its evaporation, and renewed until 
tactile sensibility is destroyed, as being as free from 
danger, in the hands of a scientific physician, as opium, 
or aconite, or hydrocyanic acid. Ether is certainly 
a powerful agent for good or evil ; but in the hands 
of experienced practitioners it is, I believe, one of 
the greatest boons ever conferred on man. 

The administration of the anaesthetic being the 



ASSISTANTS IN OPERATIONS. 323 

business of one assistant, the duties of the others 
must be regulated by individual operations. In order, 
therefore, to specify these duties more accurately, 
I shall refer to them, as required in the opera- 
tion of 

AMPUTATION. 

Amputation, when practised on the larger extre- 
mities, requires at least two professional assistants 
and two nurses or other attendants. 

The First Assistant should apply the tourniquet, 
and watch its effect upon the hemorrhage during the 
incisions ; holding the upper portion of the limb until 
the skin is divided. In the circular operation, he 
should then assist in the retraction of the skin ; in the 
flap, favour the division of the flesh on each side of the 
bone. Then, when the surgeon is ready for the 
saw, apply the retractor, and protect the soft parts 
from injury, holding the upper portion of the limb 
steady whilst the bone is being divided. Next, re- 
moving the retractor, let him sponge the stump, tie 
the ligatures, or seize the vessels. Then dry the 
skin, favour the application of the dressing and the 
proper tightness and position of the tourniquet in 
case of hemorrhage, leaving it generally loosely ap- 
plied to the limb, until all risk of secondary bleeding 
has passed. 

The Second Assistant should hold the lower por- 
tion of the limb perfectly steady, in such a position 
as the surgeon may direct. He should be especially 
careful in this duty when the saw is applied, and 
especially not elevate the limb, as this will cause 
the saw to bind, nor depress it, lest he splinter 
the bone before it is entirely sawn through. After 
the section of the bone, he should place the amputa- 
ted portion carefully and gently aside; not toss it 
on the floor, to the horror of the patient and his 
friends; the affection of a patient for a hand or foot 



324 OF THE DUTIES OF 

being sometimes very great. After this, he may hand 
ligatures to the surgeon, or hold the tenaculum in 
the artery, or perhaps tie the bleeding vessel, or hand 
sponges, &c, and then assist in the dressing. 

In many cases, besides the two principal assistants 
two or more others will prove useful; one may aid 
in keeping the patient quiet, encourage his spirits, 
give him drink, &c, whilst the other may wash and 
hand sponges, empty basins, obtain fresh water, &c, 
brandy, ammonia, and similar restoratives being 
provided by that assistant who may require to use 
them. 

After this or any other operation, when the assis- 
tants are required to remove the patient to bed, or 
to change his position, they should recollect the 
directions given at page 239, on the treatment of 
fractures, with reference to this duty. 

LITHOTOMY. 

As the lateral operation, for the removal of stone, 
is that which is most frequently performed in the 
United States, and as the gorget is the instrument 
resorted to by most surgeons, I shall limit myself 
to the operation, as performed under these circum- 
stances. 

The position of the patient should be on his back, 
with the palms of his hands embracing the soles of 
his feet ; with the thighs widely abducted, but not so 
much so as to prevent the head of the femur acting 
perpendicularly on the acetabulum, as the pelvis is 
steadied by the direct pressure made on it through 
the femur. 

Three assistants are in this operation very neces- 
sary, indeed I might almost say absolutely so. 

The First Assistant should stand on the side of 
the patient, hold up the scrotum and testicles, and 
hold the staff, after the surgeon has arranged it in 
the bladder, and satisfied all parties of the presence 



ASSISTANTS IN OPERATIONS. 325 

of the stone. The importance of the proper perform- 
ance of this latter part of his duty will, doubtless, 
be thoroughly explained to him by the operator, 
should he not be aware of it. The next point in his 
duty is to hold the staff perpendicularly to the belly, 
and with its convexity slightly inclined to the left 
side. I cannot, however, think that a surgeon 
familiar with the anatomy of the perineum, would 
wish the staff held otherwise than perfectly in the 
urethra, with the point well in the neck of the bladder, 
and without its pressing towards the rectum, or bulg- 
ing on the perineum, or inclining markedly to the 
left side, as his anatomical skill, and not the staff, will 
furnish him with the knowledge of where he is to cut. 
But as surgeons differ on this point, the assistant 
should be guided in his course by the views of the 
operator. When the surgeon takes the gorget, the 
assistant should yield the staff to him and await the 
incision of the bladder, when again taking the staff 
he should withdraw it from the part. 

The Second and Third Assistants, having precisely 
the same duties, may be referred to under one head. 
They should, after the surgeon has introduced the 
staff and proved the presence of the stone, pass the 
patient's wrists through the loops that must be made 
on the end of the bandage when prepared for this 
purpose, and make it hold firmly around the joint. 
Then placing the sole of each foot of the patient in 
the palm of each of his hands, let them by a series 
of figure of 8 turns bind the patient's hands and feet 
firmly together. Next, let each of the two assistants 
place himself so that the knee of the patient will come 
easily into his axilla ; his hand and arm of that side 
being passed around the inside of the patient's leg 
and knee ; his opposite hand grasping the patients 
ankle, and the back of his buttock being placed so 
as to press against the outside of the patient's thigh. 
Then recollecting that the patient's heel must rest on 
28 



326 OF THE DUTIES OF 

the edge of the table or bed, and that his pelvis is to 
be fixed against the table or bed by perpendicular 
pressure through the head of the femur, the assistants 
should separate the thighs to the proper distance, 
that is, until the perineum is made tense ; hold the 
knee firmly in their axilla, and let the weight of each 
of their bodies be made to bear on the top and inside 
of the patient's knee ; when he will be rendered per- 
fectly secure. He cannot now extend his leg because 
his foot is tied fast to his hand; he cannot separate 
his thighs too widely because he is resisted by the 
back or side of the body of each assistant ; he cannot 
close his knees without being strong enough to drag 
the two assistants towards each other ; and he cannot 
raise his pelvis, because he is pinned down by the 
weight of each assistant acting on his knee and 
through his femur directly on his pelvis. But if the 
assistants do not place the patient's knees in their 
axilla, and bear the greater part of their weight upon 
them, or if they abduct the limbs so as to hold them 
in a lateral position to the pelvis instead of perpen- 
dicularly to it, the surgeon will be delayed in his 
operation, or the patient, by a sudden motion, may 
ruin himself for ever. 

After the extraction of the stone, the second or 
third assistant may hand the syringe, barley-water, 
&c, if it is necessary to wash out the bladder, and 
then when all is completed, remove the bandages and 
free the patient's hands and feet ; resorting to frictions 
if they find the circulation of these parts has been 
much obstructed by the bandages. 

As in amputations, so in lithotomy, will other assist- 
ants^ useful in restraining the patient's movements, 
furnishing drink, stimulants, sponges, water, &c. 

In the operations for the Ligature of Arteries, Re- 
moval of Tumours, Resection of Bones, &c, similar 
general plans might be laid down. But as the above 
operations have illustrated the general duties to which 



ASSISTANTS IN OPERATIONS. 327 

I referred, and may serve to furnish points to con- 
siderate assistants under all circumstances, I shall 
not treat of them in detail. The duties of assistants 
in arresting hemorrhage, &c, will be found under 
that head. 

Every assistant should, as far as possible, acquaint 
himself with any operative or other peculiarities pos- 
sessed by the surgeon, and endeavour to act accord- 
ingly ; and both the operator and the assistants should 
most distinctly understand that they are to confine 
themselves strictly to their proper sphere. If a sur- 
geon after arranging his assistants chooses to try 
and do everything himself, or if each assistant in 
his anxiety to aid the operator tries to furnish him 
with whatever he wants, they will all soon find the 
operation proceeding in glorious confusion. Let the 
rule of every operation always be, "a place for every 
one, and every one in his place." 



CHAPTER II. 

OF BLOODLETTING. 

By this term is understood the use of any means 
intended to take blood from the body, with the view 
of preventing disease. These operations may, there- 
fore, be divided into several kinds, according as they 
are practised upon the superficial veins by means of 
lancets, leeches, cups, &c, or upon the arteries. 
When the extraction of blood is made by a single 
opening cut in one of the veins, it takes the name 
of Phlebotomy, or General Bloodletting ; when from 
an artery, that of Arteriotomy ; and when done by 
the aid of leeches, or cups, it is especially designated 
as Local Bleeding. First — 

OF PHLEBOTOMY, OR VENESECTION. 

This operation maybe practised upon the veins of 
various parts of the body, as at the bend of the arm, 
the back of the hand, the leg, or neck ; though the 
first is by far the most common. At the bend of 
the arm we find generally five veins, arranged so 
as to form a figure not unlike the letter M. These 
veins are, the Cephalic, Basilic, Median, Median 
Cephalic, and Median Basilic, a slight reference to 
the surgical anatomy of each of which must precede 
the steps of the operation. 

The skin in front of the bend of the arm being 
smooth, soft, and thin, these veins are generally 
seen bulging through it, or indicated by dark blue 
prominences. When not thus seen naturally, they 
may be rendered more apparent by a ligature ap- 
plied above the elbow, as in (Fig. 193) or they may 



BLOODLETTING. 



329 



Fig. 193. 



be known by their elastic feel, and by their swelling 
under the finger, when friction of the forearm has 
caused the blood to accumulate within them. Under- 
neath the skin we have the adipose tissue, which 
varies considerably in its amount, but is never 
wholly wanting. As the 
superficial veins, or those 
opened in venesection, lie 
between this adipose tissue 
and the fascia covering the 
muscles, the amount of fat 
necessarily affects very ma- 
terially the facility of oper- 
ating, because the veins, 
being deeply placed, are 
more liable to escape the 
puncture of the lancet. Be- 
neath the fascia, yet only 
at the depth of two lines, 
or thereabouts, lies the 
brachial artery, or some- 
times the radial or ulnar, 
according to the point of 
division of the brachial into 
the latter. Of the five 
veins before referred to, 
the Cephalic is on the out- 
side ; the Basilic on the inside ; the Median in front 
of the arm ; and the Median Cephalic, and Basilic, 
run from the middle to either side, to join the main 
trunks. The External Cutaneous and the Internal 
Cutaneous Nerves are those mainly liable to injury ; 
but their position varies so frequently that I cannot 
pretend even to refer to them, as it would be inad- 
missible in a description which is only intended for 
an outline ; it being expected that in this, as in 
other operations, the anatomy of the part will be 
26* 




330 BLOODLETTING. 

learned before any one would commence opera- 
ting. 

As the great variety existing in the arrangement of 
the vessels of the arm renders it, also, almost impos- 
sible to designate every spot where some unexpected 
accident, especially the wound of a nerve, may not 
occur, I can only point out, in general terms, the 
best mode of operating, and then refer to the acci- 
dents likely to arise from the operation, with the 
means of cure. 

The easiest vein to bleed in at the bend of the 
arm, on account of its size and fulness, is the Median 
Basilic, but it is at the same time more dangerous 
than the median cephalic, on account of the position 
of the artery. The latter may, however, generally 
be felt pulsating, and by opening the vein by a 
slightly horizontal cut, or by moderately flexing the 
arm, especially if the operator is cautious in his 
movements, there is but little risk of injury to this 
vessel. Some bleeders recommend turning the hand 
into strong pronation, because it assists in preventing 
accidents, either by throwing the muscles more over 
the artery on the cephalic side, or relaxing the fascia, 
and making it more difficult to cut, on the basilic 
side ; and I believe it to be a good practice, the risk 
of wounding the tendon of the biceps being not 
worthy of consideration, as compared with the safety 
of the artery. 

The varying position, however, of both arteries 
and nerves, render it difficult to foretell their injury, 
and the general rule in bleeding, therefore, is to 
take the vein that is fullest, provided the artery is 
not too near, and leave the nerves to chance. In 
several hundred cases, I have never met with the 
slightest accident ; whilst others, who were proba- 
bly equally, if not better informed than myself, 
have experienced considerable inconvenience. In 
thin subjects, owing to the deficiency of adipose tis- 



BLOODLETTING. 331 

sue, the veins are nearer the skin, but being also 
looser are more liable to roll under the lancet; 
whilst in fat persons, though more firm and less 
moveable, they are less readily seen. The depth of 
the incision must, therefore, be regulated by the 
obesity of the patient. It will also be found advan- 
tageous for the operator to accustom himself to 
bleed by the touch rather than the sight, and to 
practice his fingers on deep-seated veins, or those in 
fat arms, until he can distinguish the elastic feeling 
of a vein from the tenseness of a tendon, or the 
pulsating cord of an artery. With a view of soften- 
ing the skin, and rendering the touch more delicate, 
some bleeders moisten the finger in the mouth before 
searching for the vein. It is, however, a filthy 
practice, and one that is of little assistance ; if the 
finger of the operator is not sufficiently delicate in 
its touch let him soak it in warm water, but not 
spit on it. The risks of the operation will be treated 
of hereafter. 

Previous to bleeding at the bend of the arm, a 
simple circular bandage, or a ligature, should be 
placed with moderate firmness just above the elbow, 
so as to arrest the circulation in the veins. This 
ligature must not, however, be so tight as to arrest 
the circulation in the arteries, and to judge of this, 
the operator, after tightening the ligature, should 
feel the pulse. After a certain amount of friction 
to fill the veins, the forearm should be either held 
in an extended position by an assistant, or placed 
between the chest and the bend of the operator's 
arm ; or in his axilla ; or the patient may rest his 
hand on the top of a stick. The operator should 
then endeavour to feel beneath the vein, by making 
firm pressure on it, for the position of the artery, 
and if he finds the vessel pulsating, should open the 
vein selected, by a more horizontal cut than is usual, 
or choose another vein, or change the relative posi- 



332 BLOODLETTING. 

tion of the vein and artery by strongly pronating 
the hand, as before stated. He should then place 
the thumb or fingers of his left hand on the vein, 
below the point at which it is to be opened, in order 
to steady it. Then holding the lancet in his right hand, 
and facing the patient, if he is bleeding in the right 
arm, or in the right hand, with his back to the 
patient, if in the left arm, let him cut through the in- 
teguments, and open the anterior parietes of the 
vein ; still pressing on the vein, below the opening, with 
his left hand. The basin or cup to hold the blood 
being previously placed, and the clothes around pro- 
tected by a sheet, he should then remove his finger 
from off the vein, and immediately the blood will fly 
into the bowl. This pressure with the fingers of the 
left hand, below the orifice, will be found to be a 
neater plan than that usually pursued, of allowing 
the blood to escape immediately on opening the vein, 
as it protects the clothes or bed from the blood. 

The Lancets with which bleeding may be prac- 
tised are of two kinds, viz., the Spring and the 
Thumb Lancet ; either being used according to the 
views of the operator or the wishes of the patient. 

The Spring Lancet is an old German instrument, 
of some 300 years date, and consists of a metallic 
case on the outside of which is a trigger, whose point 
is inserted under a spring, when the instrument is 
set. Below the spring, on the inside, is placed the 
fleam or blade, which is drawn up to the spring pre- 
vious to operating. Occasionally, another and 
smaller spring is placed on the inside, under the 
fleam, in order to keep the latter constantly in con- 
tact with the spring moved by the trigger ; but it is 
an unnecessary addition, and in fact does harm, as it 
weakens the driving force of the lancet by opposing 
the descent of the fleam. 



BLOODLETTING. 333 

The Thumb Lancet, also of very ancient origin, 
is made of a simple piece of steel fastened between 
two handles, and intended to be pushed into the 
vein by the hand of the operator. Three kinds are 
employed, viz., the barley-corn or obtuse-pointed ; 
the spear or oat-pointed ; and the serpent-tongued ; 
although the last is now nearly obsolete. 

Considerable diversity of opinion exists in the 
United States, both in the minds of patients and oper- 
ators, as to the advantages of these instruments, and 
the prejudices of some are so strong against the Spring 
Lancet as to prevent its use, and vice versa. In 
some parts of Europe, as in England, France, &c, 
and in the eastern and northern portions of the 
United States, the thumb-lancet is preferred ; whilst 
in other portions, as in the southern, middle, and 
western portions of our country, the spring is almost 
entirely used. The use of the Thumb Lancet is 
thought by some to require less skill, and therefore 
to be better suited to general use ; but as far as my 
experience goes, the spring is attended by the least 
pain to the patient, and danger to surrounding parts. 
I have known sea-captains, supercargoes, sailors, 
nurses, and others, who have used the Spring Lancet 
without any accident, who yet were perfectly ignorant 
of the difference between a vein and an artery ; con- 
sequently, I regard this objection as void; whilst very 
many, from too great boldness and force, will inevi- 
tably transfix the artery with a Thumb Lancet, 
having no idea of the depth to which they should 
go. In skilful hands, the Thumb Lancet is proba- 
bly the most surgical instrument; but it gives the 
patient much more pain, the vein is more apt to roll 
from under it, and the opening is often not sufficiently 
free to prevent thrombus. For these reasons I in- 
finitely prefer the Spring Lancet, as I can bleed with 
it more horizontally in cases where the artery is near 
the vein ; give the patient no time to shrink before 
its puncture ; cause him little or no pain ; regulate 



334 BLOODLETTING. 

very accurately the depth to which I would go, by 
regulating the height of the fleam above the vessel, 
and as yet have never seen a vein transfixed by it, 
the resistance of the integuments and of the vessel 
generally overcoming somewhat the force of the 
spring. Even in young children I have invariably 
used the Spring Lancet, and although I have oper- 
ated on those as young as eighteen months, have 
never had any difficulty from the operation. Never- 
theless, every bleeder should be able to employ either 
instrument, so as to yield to the prejudices of a 
patient, and thus avoid drawing upon his own head 
the reproaches that might ensue upon the occurrence 
of an accident, under different circumstances. 

If the Spring Lancet is preferred, it should be 
Fig. 194. 




held between the forefinger and thumb of one hand, 
with its blade obliquely to the circumference and 
axis of the vein selected ; so that, on the trigger or 
button being touched by the finger, the blade may 
be driven into the vein, obliquely to its axis and also 
a little on its side : being then less likely to wound 
subjacent parts. 

If, however, the Thumb Lancet is the one used, 



BLOODLETTING. 



335 



the operator should proceed as follows; bend the 
blade to a right angle with the handle, and place 
it in the mouth, with the point of the blade turned 
from the hand that is to take it, lest when, after 
completing the preliminaries, his hand is raised to 
his mouth to seize the instrument, he should injure 
himself by sticking its point into his own hand. 

In using this lancet, seize the blade between the 
thumb and forefinger of the hand that is preferred, 
and rest the third finger of the same hand on the 
arm, as a point of support. Then placing the point 
of the lancet on the vein that it is wished to open, 
push it suddenly inwards, upwards, and outwards ; 



Fig. 195. 




depressing the handle in a circle, so as to make a 
free incision in the line before spoken of. With 
either instrument, after having drawn the amount of 
blood that is desired, undo the ligature above the 
elbow, seize the skin about the opening between the 
the thumb and fingers, so as to close the wound, and 
wiping the arm clean, place a small compress over 
the opening, and confine it by adhesive strips or by 
a figure of 8 bandage of the elbow, as before shown. 
The operation being now completed, particular atten- 
tion should be paid to the cleansing of the lancet, in 
order to prevent difficulty at the next call for its 



336 BLOODLETTING. 

use, as a dirty lancet frequently causes abscesses of 
the part, gives rise to phlebitis, and otherwise en- 
dangers the life of the patient. If the opening in 
the skin and that in the vein do not correspond, a 
bloody tumour, called a Thrombus, will be formed. 
This consists in the escape of the blood into the cel- 
lular tissue beneath the integuments. As it forms 
slowly ; sometimes attains the size of a small egg and 
has occasionally a pulsation, in consequence of the 
superficial position of the artery, young bleeders 
are apt to view it as a most serious matter, and 
expect to find an aneurism, or other serious 
difficulty. It is in reality a very simple matter, 
being little more than a large blood blister. Its 
treatment is consequently also very simple, and con- 
sists in enlarging the orginal opening in the skin, 
or in making pressure on the swelling, or in simply 
leaving it to be absorbed by nature, assisted by 
moderate pressure. 

In Bleeding in the Hand the only rule to be 
observed is, to open with a Thumb Lancet that vein 
which is most easily seen. This is generally the 
Vena Salvatella, or the Cephalic of the Thumb, 
avoiding the tendons, and guarding against a deep 
puncture, for fear of injury to the parts beneath. 

Bleeding in the Exteknal Jugulab Vein is 
now seldom practised, because the other veins gene- 
rally furnish a sufficient amount of blood, or because 
it is less cleanly than venesection in the arm, or on 
account of the danger of the introduction of air into 
the vein. In cases, however, of great cerebral con- 
gestion, as in apoplexy, or in infantile convulsions, 
it is occasionally practised, and I think may be re- 
sorted to with advantage. When deemed necessary 
it should be done as follows : — 

Place a thick, graduated compress on the base 



BLOODLETTING. 



337 



of the vein just above the clavicle, and fix it by a 
narrow cravat, the ends of which should tie in the 
opposite axilla, Fig. 196 ; or else apply an oblique 
bandage of the neck and axilla, as before shown : 
or, compress the vein with the thumb, though by this 
plan there is more danger of the entrance of air into 
the vein, from the compression being more imper- 
fect. If the vein does not become apparent from this 
compression, direct the patient to move his jaws as 
in mastication, and it will soon fill. When filled, 
open it with a Thumb Lancet, at its lower third, and 
place a bent card, or other substance likely to form 
a little trough, just below the opening, so as to carry 



Fig. 196. 




the blood off to the receiver, and thus prevent its 
trickling down the patient's side. Having taken the 
amount desired, close the orifice, as in the arm, by 
pressure of the thumb and forefinger, and fasten a 
29 



338 



BLOODLETTING. 



little compress over it by adhesive strips, before re- 
moving the bandage below the vein, as this will 
ensure the non-entrance of air to the vein, an event 
which is very apt to prove almost instantly fatal. 

Bleeding at the Ankle is generally performed 
in the Internal Saphena vein just above the mal- 
leolus, where it is very superficial ; though it is also 
occasionally practised in the foot itself, or in the 
external saphena vein. 

Operation. — In order to bleed in the veins of the 
leg or foot, the operator will require a ligature, &c, as 
in the other cases, and also a bucket of warm water, 

in which to plunge the foot 
•%• 19 7- previous to the operation. 

Then, the patient being 
seated, the limb is to be 
placed in the hot water as 
high as the calf, in order 
to assist in filling the vein 
and render it more appa- 
rent. After some minutes 
it should be removed ; the 
ligature applied about four 
or six inches above the 
malleolus, and the heel 
placed upon the point of 
the operator's knee, or on 
a low stool. A thumb 
lancet being previously 
held in the mouth, and 
the vein, steadied by pres- 
sure with the fingers, is 
then to be taken in that hand which is most convenient, 
and the vein opened, by a wound (Fig. 197) which 
should be rather longer than the one made in the 
arm, in order to give a free discharge to the blood, 
which here seldom escapes in a stream ; it being 




BLOODLETTING. 339 

more commonly necessary to replace the limb in 
the warm water, in order to facilitate its flow, than 
to see it escape in a jet. The wound should not, 
however, be allowed to sink into the water, but 
remain just above it, whilst the amount of blood 
taken must be judged of by the discoloration of the 
liquid. When satisfied as to the proper quantity, it 
only remains to remove the ligature, wipe the limb, 
and confine a compress over the opening by the figure 
of 8 bandage of the ankle. 

The only accident likely to result from bleeding 
at this point is, the wounding of the saphena nerve : 
the arteries being distant. Should the nerve be 
wounded, either in this or any of the other opera- 
tions, it will be shown by pain, by twitchings, tingling, 
&c. To treat this injury it is usually necessary to 
apply a warm poultice ; keep the limb at perfect 
rest for a couple of weeks, and use the antiphlogis- 
tic system generally. 

Bleeding in any of the veins may be followed by 
irritation of the edges of the wound ; by abscess, or 
by erysipelas. Any of these accidents will be best 
combated in the first stage, by resorting to the poul- 
tice and other measures just referred to, and by such 
subsequent treatment as the knowledge of each 
practitioner will readily indicate. 

From want of proper attention in the selection of 
the vein, or from want of skill on the part of the 
operator, it occasionally happens that an artery is 
opened. This serious accident may be readily told 
by the brighter red colour of the blood ; by its es- 
caping in jets which are synchronous with the pulsa- 
tions of the heart ; by the blood continuing to flow, 
notwithstanding firm compression of the vein below 
the opening ; or by noticing the change in the colour 
of the blood produced by a very firm compression of 
the artery alone, above the wound. When thus satis- 
fied of the nature of the accident, the operator should 



340 BLOODLETTING. 

endeavour to guard against his suspicions of it being 
seen by those around, in order to prevent alarm ; 
and if the state of the health of the patient does 
not absolutely forbid it, let the blood flow till faint- 
ing is induced, when he may arrest it by a firmer 
compression than is requisite when the vein alone 
is opened. To do this, make, by means of several 
small graduated compresses, or by a thick pyramidal 
compress, a cone, the point of which shall rest upon 
the wounded vessel ; fasten it by a firm figure of 8 
bandage of the elbow, and apply the Spiral of the 
Upper Extremity, from the fingers up to the upper 
part of the limb. This treatment should then be 
continued for fifteen days or more, by which time 
the closure of the opening in the artery will gene- 
rally be effected, though most probably an operation 
for aneurism will be required. Yelpeau and others 
have, however, seen cases in which the wound in the 
artery closed, without there having been at any time 
sufficient compression to stop the puliation at the 
wrist. Let it, however, be remembered, that proper 
attention will enable an operator to avoid this serious 
accident, and that when it happens, it will generally 
be his own fault. 

Besides the veins above mentioned, bleeding was 
formerly practised in many others, as the occipital, 
auricular, frontal, sub-lingual, dorsalis-penis, &c, 
but the introduction of leeching has done away with 
these operations. Where, however, leeches cannot 
be had, and it is desirable to take blood directly 
from the part, these veins may be opened by ope- 
rating as in other veins, it being borne in mind that 
such operations should always be performed with a 
Thumb Lancet, the orifices in the external veins 
being afterwards closed by a compress, adhesive 
strips, &c. ; and that in the sublingual, and others, 
by the application of cold, or salt and water, or 
astringents. 



BLOODLETTING. 341 



ARTERIOTOMY. 

This operation, which was practised to some extent 
by the surgeons of the sixteenth, seventeenth, and 
eighteenth centuries, and highly thought of by Hip- 
pocrates, Galen, and Celsus, has been almost entirely 
abandoned by those of the present time, no one now 
ever thinking of bleeding in the radial artery, or 
opening the lingual, or those of the mastoid region, 
and very few of opening the temporal. Should this, 
however, be deemed proper, and should there be no 
other way of drawing blood from the part to be 
benefited by the operation, the smaller arteries should 
be selected, as the anterior branch of the temporal, 
and not the main trunk. 

Operation. — The patient being seated, with the 
head supported, or else lieing down, feel for the pul- 
sation of the vessel, about fifteen lines in advance 
of, and above, the meatus auditorius externus, where 
the artery is almost without the temporal fascia, 
close under the skin, and well supported by bone. 
Then, with a lancet or bistoury, cut the vessel in 
half transversely, either by cutting from the skin 
inwards, or, what is better, from within outwards, 
as seen in Eig. 196, the instrument being previously 
introduced below the vessel. The artery should 
never be, as a general rule, opened longitudinally, 
because the contraction of its muscular coat would 
tend to close the orifice, and stop the hemorrhage. 
As soon as the vessel is opened, the blood flies in a 
jet, and maybe either received directly into a basin, 
or else drawn off by a bent card or trough, as in the 
operation on the jugular vein. Should the bleeding 
tend to stop, before blood enough is taken, we should 
apply warm clothes to the part, wash out the clot, 
&c. ; but if enough has been taken, then compress 
the vessel below the puncture ; close the wound ; apply 
a compress, and fasten it either by a simple circular 
29* 



342 BLOODLETTING. 

bandage of the vault of the cranium, or by the knotted 
bandage, shown before. I cannot but think, that 
except in very urgent cases, this operation, at the 
present day, can ever be necessary, safer means ac- 
complishing the same purpose and avoiding the sub- 
sequent formation of aneurism, or the scar from the 
tieing of the vessel, which are often disagreeable 
and troublesome. 

LOCAL BLOODLETTING. 

The name of Local Bleeding is generally given to 
the operation in which the smaller vessels, and those 
close to the diseased part, are opened. It may be 
practised by means of Leeches, Cups, or Scarifica- 
tions. 

LEECHING. 

The Leech is an animal of the inter-vertebrated 
articulated family, Annelidae, and has been employed 
in medicine from almost time immemorial. This 
species, Hirudo Medicinalis, is an aquatic worm, 
with a compressed body, tapering towards each end 
and terminating in circular flattened disks ; the 
hinder one being the larger of the two. It swims 
with an undulating motion, and moves when out of 
the water by means of these disks or suckers : 
fastening itself first by one, and then by the other, 
and alternately stretching out and contracting its 
body. The mouth is placed in the centre of the 
anterior disk, and is furnished with three cartilagi- 
nous, lens-shaped jaws, lined at their edges with fine, 
sharp teeth, which meet so as to make a triangular 
incision in the flesh. It varies from two to three or 
four inches in length, and inhabits most of the marshes 
and running streams of Europe, and many parts of 
the United States. 

Leeches afford the most effectual means of abstract- 
ing blood locally, being often applicable to parts 
which, from their situation or great tenderness, would 



BLOODLETTING, 



343 



not admit of the use of cups, and, in the case of in- 
fants, are always preferable to the latter. 

In order to apply them with ease to any part, care 
should be taken to free it, by washing, from all medi- 
caments, and by shaving from all the hair or down 
on the skin. If the leech is very active or hungry, 
it will readily attach itself to the part when thus 
cleansed : but generally it is necessary to moisten 
the surface with a little blood, or with milk, or with 
sugar and water, when the leech will readily leave 
the vessel containing it, and attach itself to the skin. 
If it is desirable to attach a leech to any one point, 
place it in a large quill or glass tube, and put this 
directly on the part ; when, as the animal cannot 
escape, it will readily adhere. But when the part 
is not so circumscribed, it suffices to apply the edge 
of the cup containing them just below the point, and 
let them crawl on to it ; or place them under a 
tumbler, and by confining their wandering, cause 
them to attach themselves to the portion beneath 
the glass (Fig. 198). 

Fig. 198. 




Where blood is wanted to induce them to bite, it 
may be readily obtained by tieing a string tightly 



344 BLOODLETTING. 

round the extremity of the finger, so as to render it 
turgid, and then lightly pricking it with a lancet ; 
the blood escapes in points, and may then be smeared 
on the part. This operation causes no pain, unless 
very often repeated on the same finger. But if a 
part is thoroughly cleansed from all secretions, 
hairs, &c, and care is taken in the preservation of 
the leech, it will attach itself without necessitating 
this operation. 

Leeches continue to draw blood until they are 
gorged, when they drop off. But if it becomes ne- 
cessary to remove them before they are thus filled, 
it should be done by washing them with a little salt 
and water, and not by pulling them off; as this is 
very apt to leave the teeth in the wound, where it 
serves as an irritant, besides being destructive to 
the leech. Six American leeches are calculated to 
draw one ounce of blood ; but as their bites fre- 
quently bleed as much as the animal itself drew, 
this is but an approximation to the quantity. Some 
persons are in the habit of cutting off the tail of the 
leech, in order to cause it to continue sucking for a 
long time, as the blood passes out as fast as swal- 
lowed ; but it is a barbarous practice, and of course 
destructive to the utility of the animal. After the 
leech has come away, the bites continue to bleed, 
and this may often be encouraged by the application 
of flannels, and cloths wrung out of hot water. But 
if it is not desirable to take this extra amount of 
blood, cover their bites with a piece of linen, moist- 
ened in sweet oil, or spread with fresh lard or cerate. 
Occasionally it happens, in the case of children or 
weakly individuals, that the after-bleeding is pro- 
fuse and debilitating, and that it is absolutely 
necessary to arrest it at once. Various measures 
have, therefore, been recommended, but I have 
generally found, under these circumstances, that it 
is only necessary to touch each bite with a sharp- 



BLOODLETTING 345 

pointed piece of lunar caustic, or to dry the spot 
thoroughly, and then apply over it a small piece of 
patent lint or cotton, wet with collodion. A hot 
needle, stitches, &c, have been recommended, but 
the above is less painful, and more readily applied. 
In our large cities, where leeching is the peculiar 
business of a class of individuals, there is generally 
no difficulty in their employment ; but with the 
country practitioner it is different, as he must pre- 
serve and apply them himself, and this is found to 
be a very onerous duty. Let it, however, be recol- 
lected, that their application is sometimes a matter 
of absolute necessity ; that, as above shown, it is 
simple, and two of the objections to their use are 
removed. Their preservation is then the only point 
of difficulty, and this may be obviated by a slight 
attention to the habits of the animal. The leech, 
when gorged, remains inactive or unfit for use for 
several weeks, and is also liable to disease, by which 
numbers are lost. All that is necessary to guard 
against this, is perfect rest in a vessel of fresh water ; 
in a few weeks they will again be fit for use. The 
preservation of them by the following rules is easy, 
and always ensures a supply: Never squeeze them 
to cause them to disgorge, it brings on disease. 
Place them in clean water, and change it frequently. 
Then, in order to keep them in health and ready for 
use, place them in a cool place, and arrange a mix- 
ture of moss, turf, and fragments of wood at the bot- 
tom of the vessel containing them, laying a few 
stones on the pieces to keep them in position. Place 
in it, also, a piece of wood or earthenware filled with 
small holes, so that the leech may keep up its natural 
habits, and by drawing itself through the holes in 
the board or through the moss, sticks, or stones, 
free itself from the secretion of slime found on its 
body, which otherwise becomes the cause of disease. 
By changing the water occasionally, and keeping 



346 BLOODLETTING. 

the trough, tub, or jar, covered with a piece of mus- 
lin, in a cellar, any practitioner can always have a 
supply of these useful animals at his command. Let 
it be recollected, however, that those which have been 
used are to be kept separate from the others for 
about two months, when they may be replaced in 
the trough till again called for. If, in applying 
leeches to any point of the body whence they might 
escape to internal parts, as about the anus, the mouth, 
&c, they should remain in these parts, they may be 
at once destroyed and ejected, by the free use of salt 
and water, either as an emetic or enema. But the 
fear of any internal injury from them is groundless, 
as the heat and other peculiarities of the parts will 
at once destroy them. 

MECHANICAL LEECHES. 

A substitute for the leech has recently been sug- 
gested by Mr. Alexander, of Paris, and named as 
above. They consist of small glass tubes with 
bevelled ends, the air within each one being exhausted 
by a very ingenious and simple mechanism. Applied to 
the surface of the body they act like small cups, and 
produce congestion of the superficial vessels. Then 
a small metallic tube, containing a three-bladed or 
triangular lancet, makes a puncture of the skin ; after 
which, the glass leech is re-applied as often as may be 
necessary, precisely as in the ordinary operation of 
cupping. 

In several instances in which I have employed these 
leeches they acted well, and satisfied me that to the 
country practitioner, under ordinary circumstances, 
they would prove very useful, although I do not think 
they can supplant the aquatic leech, especially in the 
abstraction of blood from small regions, as the eye- 
lids, gums, nostrils, rectum, &c. Being put up in 
boxes containing a dozen or more, and sold at a 
moderate price, they will, however, claim the atten- 
tion of all practitioners who are so situated as not to 



BLOODLETTING. 347 

be able to obtain or apply the natural leech. As 
agencies for the sale of the Mechanical Leech now 
exist in both Philadelphia and New York, the drug- 
gists can readily furnish them. Printed directions 
accompany each case, and render their mechanism 
perfectly intelligible. 

CUPPING. 

By the word Cup, is understood a little bell-glass, 
three to four inches high, from which we exhaust the 
air, so that when applied on the skin it may cause a 
congestion of this membrane, from the pressure of 
the atmosphere upon the parts around the cup itself. 
These cups, though made of various materials, yet 
differ chiefly in the manner in which the air within 
them is exhausted; some being slightly open at the 
top, and fitted to receive the end of a small air-pump ; 
others being entirely closed, and exhausted by the 
use of fire, applied internally in different ways. When- 
ever the cup is simply applied on a part, it causes a 
flow of blood and temporary fulness of the vessels in 
the skin ; but when the flesh is cut after this applica- 
tion of the cup, the blood will flow freely from the 
incisions, on the exhausted cup being again placed 
over the part, though it could not do so previously. 
This mode of depletion is termed Cupping, or the 
application of wet cups, in contra-distinction to dry 
cupping, or that in which the cup is applied merely 
to draw the blood to the surface. When it is desir- 
able to exhaust a cup, it may be done either with the 
pump, by fitting it to the cup as prepared for it, 
applying the latter to the part perpendicularly, and 
then working the piston once or twice as in any ordi- 
nary syringe : or by the use of fire to rarify the air 
within the cup itself. 

With the latter view, various means have been 
employed ; thus the air may be rarified either by the 
rapid insertion of a candle or little torch, followed by 



348 BLOODLETTING. 

the instant application of the cup to the part ; or else 
fire may be placed in the cup and it at once put on 
the skin. To do this, some practitioners shake a 
little alcohol around the inside of the cup, pour out 
"what flows readily, and inflame the little that adheres 
to the glass by a lighted piece of paper ; others in- 
troduce small balls of inflamed cotton saturated with 
alcohol ; others simply use pieces of burning paper ; 
but the two last cause unnecessary pain, by burning 
the skin on which they fall. The best and neatest 
way of exhausting a cup, is the following: Cut 
several pieces of letter-paper, slightly glazed, into 
strips about one inch and a-half wide. Wrap this 
round the end of the fore-finger, so that about one- 
third of its width shall project beyond the end of the 
finger, and having thus formed a little tube, tear off 
the remainder of the strip, and twist the part project- 
ing beyond the finger, so as to close up the tube, and 
form a little cap like a thimble. Dip the open end 
of this thimble lightly into alcohol ; a small portion 
will adhere to its glazed surface ; touch it in a can- 
dle ; throw it into the glass, and apply the latter at 
once to the part. The shape of the thimble is such 
that it will nearly always fall on its apex, or twisted 
end, whilst the part wet with the alcohol, or the base, 
will stand uppermost and sufficiently far from the 
skin to prevent its being burnt. Having by either 
of these modes exhausted a cup, allow it to remain 
on the surface of the part till the skin under it has 
become turgid, then, if blood is to be taken, cut the 
integuments by means of the Scarificator, and re- 
apply the cup as before ; removing it when filled or 
half filled with blood, and again applying it, if neces- 
sary. In order to remove the cup, introduce the nail 
of the fore-finger under its edge, and gently force 
the cup on to its side, so as to allow the air to enter. 
After wet cupping, the parts should be cleansed, and 
covered with cerate or an oiled rag. 



BLOODLETTING. 349 

; 

If . the regular cupping apparatus, as furnished by 
the cutler, is not at hand, we may perform the oper- 
ation very well by using wine-glasses or tumblers ; 
scarifying the parts, if blood is to be taken, by rapid 
punctures of a thumb-lancet, bistoury, or sharp pen- 
knife. 

In using the Scarificator, the operator should regu- 
late the depth of the lancets, previous to its applica- 
tion, and then place it firmly in contact with the skin 
before touching the spring, so as to avoid the lacer- 
ated incision which will probably otherwise result 
from the cut of the lancet, if loosely applied. 
30 



CHAPTER III. 

OF CUTANEOUS IRRITATION. 

Another useful method of producing depletion is by 
means of irritation, as excited by various means in 
the cutaneous exhalents ; or by the establishment of 
serous and suppurative discharges. 

These temporary inflammations are usually created 
on the surface of the body, with the view of relieving 
some internal disorder that is more dangerous to the 
life of the patient than the one thus excited, and 
when properly directed, are possessed of great power. 
Acting on the principle of revulsion, they relieve in- 
ternal inflammation, by drawing the fluids to the sur- 
face, and operate with as much certainty as any of 
the usual means of bloodletting; whilst they are, 
also, applicable to cases where the latter means would 
not be generally available, as in the chronic phleg- 
masia, &c. 

To explain fully their modus operandi, or enter 
more in detail into the cases for their application, 
would lead to the consideration of points foreign to 
my present arrangement, and I can, therefore, treat 
only of their production ; and first 

OF BLISTERS. 

The simplest drain that can be created on the sur- 
face of the body, is that arising from vesication or 
the formation of a Blister. This Blister generally 
creates only sufficient inflammation to cause an effu- 
sion of serum under the cuticle, by which the epider- 
mis is separated from the subjacent structure, and 
forms a cyst. Various substances may be resorted 
to for the accomplishment of this end. 



CUTANEOUS IRRITATIONS. 351 

The most common is the Ceratum Cantharidis of 
the United States Pharmacopeia, which is spread on 
kid, brown paper, or other substance ; applied directly 
to the skin, and left there for about five hours. Then 
on applying a poultice, vesication is readily effected 
without creating strangury or other general incon- 
venience. Various other preparations are also re- 
commended as possessing peculiar advantages, as 
Brown's Cantharidine Tissue, which act promptly, 
and with some advantages over the old blister plaster. 
But one of the neatest means that I have employed 
is the solution of Cantharidine in Collodion, called 
the Vesicating or Cantharidal Collodion. This should 
be painted on the skin as in the ordinary use of the 
liquid adhesive plaster referred to at page 49. 

If a prompt blister is required, the application of 
a piece of oiled silk over the collodion will cause vesi- 
cation in about three hours. But if the cantharidal 
collodion is simply painted on the part, and allowed to 
evaporate, it will require rather longer. The advan- 
tages of the preparation will be found in its easy ap- 
plication, in its fixedness, and in its certainty. When 
blisters are required on the temples, back of the ears, 
neck, and other perpendicular surfaces, it will recom- 
mend itself by its permanent adhesion (see Journal of 
Pharmacy, Oct., 1849). As soon as vesication occurs, 
the elevation of the cuticle arrests the further action 
of the collodion. Whenever vesication is established, 
and the serum excited by a blister has created a cyst, 
it should be punctured, and the slight ulcer left by 
removal of the cuticle, will usually heal kindly under 
the use of simple dressings, without much discharge. 
But if it be desirable to make a more permanent im- 
pression, and continue the drain, instead of merely 
evacuating the fluid first secreted, we should seize 
the cuticle with a pair of forceps ; and either cut or 
tear it from the inflamed surface ; then dress the ex- 
coriated portion with some stimulating ointment, as 



352 CUTANEOUS IRRITATIONS. 

that of savine ; of cantharides ; of mezereon ; or with 
cabbage, or beet leaves ; or with any of the other 
stimulating ointments of the Pharmacopoeia. By 
these means, a permanent blister, as it is termed, may 
be kept up for six or eight weeks, though usually the 
discharge is continued with difficulty after this lapse 
of time. In such cases, the following plan will in- 
crease the flow and create an issue on the blistered 
surface : Take two or more peas, made of orris root, 
and bind them firmly to the part, through an open- 
ing made in the cerate covering the rest of the sore. 
Continue the pressure until they ulcerate into the 
true skin, when, by the use of any of the previous 
ointments, a discharge may be kept up for any period 
that may be desired. 

A blister, however, is not often employed in this 
manner, as issues can be more readily created, and 
with less pain to the patient, by the means hereafter 
mentioned. 

When it is desirable to raise a blister in a very few 
minutes, as in cases of collapse, concussion of the 
brain, &c, the fly-blister commonly employed will 
not answer, as it is too slow in its operation. Resort 
must then be had to something more active, such as 
compresses wrung out of scalding water and applied 
directly to the part, taking care to prevent the escape 
of the liquid over surrounding parts. Or, a piece 
of thin soft paper saturated with spirits of turpentine, 
or alcohol, may be pressed firmly on the body, set 
fire to, and allowed to burn for a few seconds. This 
raises a blister with great rapidity, but is extremely 
painful to the patient if consciousness is at all per- 
fect. A plan recommended by Sir Anthony Car- 
lisle, was to lay a double folded piece of moistened 
linen upon the portion to be blistered, and pass over 
this a flat cautery iron heated to a reddish-brown 
heat. 

A neater plan than either of these, and less pain- 



CUTANEOUS IRRITATIONS. 353 

ful, will be found in the use of Granville's strong 
rubefacient lotion, or pure Aqua Ammonia, applied 
directly to the spot by means of patent lint, or pieces 
of linen saturated with it. This powerful remedy 
requires but a minute or two to raise a blister, if the 
ammonia is pure ; but, like the hot water, requires 
caution, to prevent its flowing over surrounding parts. 
The best means of accomplishing this is to pack lint 
in a pill-box until it projects above the rim, and then 
press it against the skin : the edges of the box cir- 
cumscribing the action of the lotion. Gondret's oint- 
ment consisting of strong aqua ammonia, lard, and 
suet, will also vesicate speedily, if covered with a com- 
press ; without the use of the latter it generally acts 
only as a rubefacient. As the ointments before men- 
tioned tend to increase the effect of a blister, and 
augment the discharge after its production, so a mild 
soft poultice, of any warm emollient substance, will 
generally diminish its action, when the inflammation 
runs too high. 

ISSUES 

Are drains that are most generally created by the 
action of some substance, which, by destroying the 
tissue, induces a discharge in consequence of the 
efforts of nature to repair the damage. Two classes 
of agents possess this power : 1st, Chemical Agents 
or Caustics, as commonly designated, and 2d, Heat, 
or the actual or potential cautery. Each of these 
agents, by destroying the organization of the skin, 
creates a dead mass called an Eschar. This, being- 
thrown off by nature, leaves a cavity, which being- 
filled with issue peas, or some irritating substance, 
keep it open and continue the discharge. 

Chemical Agents, or Caustics, are those most com- 
monly employed. They may be used in three forms, 
solid, liquid, and as paste. Of the solid kinds, we 
have the Potassa, or Kali Purum ; the Nitrate of 
30* 



354 CUTANEOUS IRRITATIONS. 

Silver; the Bi-Chloride of Antimony ; the Chloride 
of Zinc, &c. ; all of which act in the same manner. 
The caustic potash being readily obtained, and prompt 
in its effects, is the one most generally preferred. 

In using this article, select such a spot for its ap- 
plication as will not involve any deep-seated import- 
ant parts. Thus, superficial joints, arteries, nerves, 
bones, &c, should be avoided, less the action of the 
caustic extend to them, and produce serious injury. 
Issues should, therefore, be established in the fleshy 
part of the arm, or thigh, or on the back of the neck, 
or along the spine. If we choose the thigh, the de- 
pression which exists on its inner side, just above the 
knee, will be found convenient ; if the arm (and this 
is most common), take the space between the biceps 
and the deltoid, near the insertion of the latter. 
Then laying upon the spot selected a piece of adhe- 
sive plaster, or kid spread with soap cerate, with a 
hole in its centre of the size desired for the issue 
(generally about three lines in diameter), rub the in- 
teguments within this hole with a piece of the caustic 
potassa till they become black, and repeat the opera- 
tion each day, if necessary, until an eschar is obtained 
of the desired depth. This usually should not be 
deeper than the integuments, lest it extend beneath 
the fascia, and produce subsequent trouble. Or we 
may place in the opening of the plaster a piece of 
potassa, about the size of a hemp-seed; cover this 
with a strip of adhesive plaster, and apply over it a 
compress and bandage. After twelve hours, on re- 
moving the plaster, apply a warm poultice, in order 
to hasten the separation of the slough, which on 
coming away will leave a deep circular ulcer. This 
ulcer should then be filled with three or four peas 
made of Orris Root or Gentian, which, by absorbing 
the moisture, will swell and distend the part. Should 
they, however, not prove sufficiently irritating, dress 
the sore with Basilicon, Mezereon, or some other 
stimulating ointment. 



CUTANEOUS IRRITATIONS. 355 

The daily dressing, subsequently used, must depend 
upon circumstances. If fungous granulations arise, 
they must be repressed by the nitrate of silver ; sup- 
puration kept up by moving the peas, and by the 
ointments just stated; and too much inflammation 
prevented by the use of warm poultices and mild 
cerates. The removal of the peas, and the use of 
simple dressings, generally suffices to heal the sores. 

In order to protect the ulcer from accidental inju- 
ries, and also to keep the patient's clothes from being 
soiled by the discharge, it is usual to cover the part 
with a small plate of tin, or some other light metal, 
moulded to its shape, and fastened by an elastic band 
so as to surround the limb. These little bandages 
are generally kept by the cutlers or druggists, and 
add much to the patient's comfort. 

When, in the production of an issue, any apprehen- 
sion exists of the action of the caustic extending too 
deep, we may neutralize it by an appropriate article. 
Thus, washing the part with vinegar will neutralize 
the action of caustic potash ; salt and water that of 
the nitrate of silver ; magnesia, or some other alkali, 
that of sulphuric acid, &c. 

The formation of issues by incision has so little 
to recommend it, that I shall pass it by. 

When other means cannot be had, iron heated in 
the fire may be substituted for the caustics just men- 
tioned. Heated to a white heat, and applied directly 
to the skin, the actual cautery immediately produces 
an eschar, which follows the same course as that 
created by caustic. The fears of patients, and the 
greater convenience of other means, have, however, 
thrown this mode of creating an issue out of general 
use. 

The Sulphuric, Nitric, and Hydrochloric Acids, 
are occasionally employed, when some objections exist 
to the means just stated. In order to use them, 
steep a small compress of patent lint, fixed to the end 



356 CUTANEOUS IRRITATIONS. 

of a small piece of wood, in the liquid, and apply it 
directly to the skin, guarding against the extension 
of the acid over surrounding parts ; the eschar will 
then be made as before stated. In cauterizing the bites 
of rabid animals, the liquid caustics are preferable to 
the others, as they spread more rapidly ; but the 
wound should in these cases always be enlarged, 
previous to their use. 

OF SETONS. 

A Seton is one of our most powerful means of 
keeping up a cutaneous discharge. Strictly speaking, 
the seton itself is merely the band or substance em- 
ployed to irritate the part ; though the name is often 
given to the operation by which this band is intro- 
duced beneath the skin. Its application is now very 
generally confined to the back of the neck, though 
it may be also applied to certain other parts, as the 
fleshy part of the thigh, or arm ; but in these points, 
issues are generally preferable. 

In order to apply a seton, we require a sharp 
cutting instrument to make an opening through the 
integuments, and some strip which, when introduced, 
may, by its irritation, keep up a suppuration from 
the part. For the insertion of the strip we have 
two instruments, Boyer's Seton-Needle, and a com- 
mon straight bistoury and eyed probe. 

The first consists of a flat steel blade about five 
inches long, six lines wide, and perforated at one 
end with a hole large enough to receive the strip to 
be introduced ; the other end is sharp, and sloping to 
a point like a thumb lancet. To introduce the seton 
with this, first fasten the substance to be used in the 
eye of the needle, and then seizing a portion of the 
integuments, of the required width, between the fore- 
finger and thumb of one hand, raise it up from the 
parts below, and transfix its base by forcing the nee- 
dle through ; and drawing it and the seton out on the 



CUTANEOUS IRRITATIONS. 



357 



opposite side to that on which it entered, leaving the 
seton in the wound. After which, its ends should 
be fastened down by a little piece of adhesive plas- 
ter, and the whole covered by a warm poultice, till 
suppuration commences ; when a simple dressing is 
all that is requisite. 

The objections which I have to this method are, 
that the seton needle is not always at hand; that the 
fastening of the seton in its eye is apt to make a 
thick mass, which passes through the opening with 
difficulty, and that it is hard to seize the point of the 
needle, when wet with blood, so as to draw it through. 
I therefore prefer the straight bistoury and eyed 
probe, as generally resorted to by the French Sur- 
geons. To use this, fix the seton by a thread to the 

Fig. 199. 




eyed probe ; seize the integuments as before ; cut 
them with the bistoury, and before removing it, in- 
troduce the point of the probe from the opposite side, 
and withdrawing it and the bistoury at the same time, 
insert the seton in its place (Fig. 199). 



358 CUTANEOUS IRRITATIONS. 

In respect to the substance of the seton there is 
much diversity of opinion ; but let the substance be 
what it will, it should always be well anointed with 
ointment previous to its introduction, and also pre- 
vious to any movement of it through the wound in 
subsequent dressings, in order to facilitate its pro- 
gress or increase its action. For the first three days 
the poultice is stained by blood, or slight oozings ; 
but afterwards by pus. When suppuration has freely 
commenced the substance of the seton becomes 
charged with matter, which, if allowed to remain, 
renders it very offensive. At each daily dressing, 
therefore, the seton should be drawn through the 
wound till this soiled part is free, when it should be 
cut off, and the ends fastened down and dressed as 
before with simple dressings; the whole being con- 
fined by a circular bandage of the neck, as at Fig. 
33, or by a sling, as at Fig. 85. As the seton by this 
operation is soon cut up, it will ultimately be neces- 
sary to prepare for the introduction of a new one. 
This is readily accomplished by attaching it by a few 
stitches to the old one ; anointing it well, and draw- 
ing this into its place, as the old one is removed. A 
skein of saddler's silk, or a piece of silk braid, is the 
article most frequently employed ; but where we can 
obtain a strip of gum-elastic, or braid or tape coated 
with it, they will be found to be much more cleanly 
than the silk. 

OF MOXA. 

This is the name given to little rolls of inflamma- 
ble matter, intended to cause eschars, by being al- 
lowed to burn upon the integuments until they cause 
its destruction. They are made of various substances, 
as cotton, lint, tow, &c, soaked in a saturated solu- 
tion of nitre ; then dried and wrapped up in little 
bags, or rolls of silk, or muslin, sewed together at 
the sides, and formed into rolls and coated with gum. 



CUTANEOUS IRRITATIONS. 



359 



Or, the common punk, as found in the shops of the 
tobacconist, cut into pieces about one inch long, will 
answer the same purpose. The application of any of 
these cylinders is very simple. Having chosen a spot 
where the subjacent parts of importance are not 
likely to be injured by the extension of the inflam- 
mation, place upon it a piece of moistened cloth, with 
a hole in its centre large enough to receive the moxa. 
This cloth is intended to preserve the surrounding 
parts from the sparks which sometimes escape. Next 
see that the end of the moxa is applied to the part per- 
pendicularly, so that it may fit itself accurately to the 

Fig. 200. 




surface; then moisten it with a little gum to make'it 
adhere, or else hold it firmly on the part by a pair of 
forceps, or a porte-moxa or metallic ring, as in Fig. 
200. Having now lighted one end of the cylinder, 
keep up the combustion by the breath, or by a pair 



360 CUTANEOUS IRRITATIONS. 

of bellows, the latter being necessary where the 
smoke irritates the bronchia too much. On its ap- 
plication and burning, the patient first feels a gentle 
heat, which gradually increases, until, as the fire 
approaches the part, the pain for the moment be- 
comes excruciating, but diminishes as the fire destroys 
the vitality of the skin. The eschar thus formed 
being afterwards treated like the eschar created 
by the caustic, the issue is readily created, and the 
subsequent treatment will be similar to what was 
there said. 



CHAPTER IV. 

OF PUNCTURES. 

In various cases of accumulation of liquids and gases 
■within the cavities of the body, it is found necessary 
to evacuate them by a class of operations which 
divide the tissues in a manner somewhat analogous 
to incision, yet differing from them not only in the 
instruments employed, but also in the method of using 
them. 

In these cases, perforations are made by sharp- 
pointed instruments, of different kinds, being pressed 
or pushed beneath the skin, by a sudden movement, 
so as to divide the tissues by pressure, instead of by 
the saw-like action of the knife or bistoury. 

OF ACUPUNCTURATION. 

The simplest puncture that can be termed an ope- 
ration, is that made by the introduction of needles 
under the skin. With the exception of their employ- 
ment in exploring doubtful tumours, &c, their use is 
mainly confined to what is known as Acupunctura- 
tion. This consists in making a number of small 
punctures in the skin by means of needles of gold, 
silver, platina, or steel, shaped as in Fig. 201, and 
introduced into the part by rapidly rotating them 
between the fingers. Marked benefit, in certain cases, 
was said to have been derived from their use, and as 
they caused but little pain, the operation was at one 
time quite popular. Employed from an early period 
by the Japaneese, and others, in order to relieve 
various internal disorders, so rapid was their action, 
that miraculous powers were wildly ascribed to them. 
31 



362 PUNCTURES. 

Subsequent investigations have not, however, sup- 
ported this elevated opinion, and want of success has 

Fig. 201. 



driven the operation therefore into comparative dis 
use. Without discussing the advantages of the oper- 
ation, I shall, therefore, now simply detail the 
method of its performance. The place being chosen, 
take hold of the head of the needle, or of the handle 
into which it is sometimes inserted, with the thumb 
and fore-finger of the right hand, supporting its stem 
with the thumb and forefinger of the left. Press it, 
with a rotary motion, to the depth of several inches 
if requisite to reach the seat of pain, and leaving it 
there, introduce several others at slight distances 
apart. If the needles are sharp, and rotated rapidly, 
the pain of their introduction is very slight, and in 
certain neuralgic cases especially, there use is even 
said to be agreeable to the patient. 

But without trusting to the effects of imagination, 
we may have more confidence in another method 
of treating such patients, which has an additional 
recommendation in the employment of a narcotic. 
This consists in making numerous punctures with 
these needles, or with a sharp-pointed lancet, so as 
barely to draw blood, and then washing the part with 
a strong solution of sulphate of morphia, or by paint- 
ing it with the strong tincture of the root of the Aco- 
nitum Napellus. The application of the anodyne 
thus directly to the seat of pain, is said to relieve it 



punctures. 363 

very quickly, and must, I think, prove serviceable : 
although I have never had occasion so to use it. 

The application, however, of the ointment of aco- 
nitine, in the proportion of one grain of the aconi- 
tine to the drachm of lard, as recommended by Turn- 
bull and others, has in my hands destroyed the pain 
of the most intense facial neuralgia within a half- 
hour. 

ELECTRO-PUNCTURE. 

The advances recently made in the science of gal- 
vanism and electricity has again reviewed the opera- 
tion of electro-puncture. This operation is the same 
as the preceding, so far as the introduction of the 
needles, but differs subsequently, in its being aided 
by the action of the electric fluid directly on the dis- 
eased part. In using this fluid we must of course 
be governed by its general laws, and if we wish to 
produce only slight shocks, cause the spark of the 
apparatus employed, to fall indirectly on the head of 
the needle, shaped as at A, Fig. 201 ; but if a more 
severe action is desired, keep up a continual current 
through the needle, by direct contact with it, of the 
poles of the machine. The Electro-Magnetic appa- 
ratus is applied in the same way as the electrical 
machine, and it matters but little in Avhat way the 
fluid is applied to the needles, provided the circuit 
of the current is continued throughout them. The 
cases in which it is adapted, and their probable re- 
sults, may be found fully treated of in most of our 
Dictionaries, under this head. 

VACCINATION. 

Nothing need be said, at the present day, as to the 
advantages of this operation. Trifling as it is, its 
proper effect depends in a great measure on its cor- 
rect performance, and passing by, therefore, much 
that has been stated in regard to the shape, size, and 



364 PUNCTURES. 

number of the punctures, I shall merely mention the 
plan that I pursue and have very generally found 
successful. 

Scrape slightly the epidermis, on the spot selected, 
with a moderately dull thumb lancet, until it removes 
a small amount of the cuticle, in the shape of a light 
dust. As soon as the skin underneath becomes pink, 
or shows very minute points of blood, place a drop 
of the liquid from the pustule, or from the dried scab, 
softened and made liquid by water, upon the abraded 
surface, and press it beneath the skin by three or 
four slight punctures with the point of the lancet 
(Fig. 202), just deep enough to tint the matter with 

Fig. 202. 




the blood, but not so as to make the part bleed freely ; 
then keep the arm exposed to the air until the matter 
dries or hardens. In order to guard against subse- 
quent irritation, tie up the child's sleeve to the shoul- 
der, or cover the spot operated on with a piece of fine 
linen. 

The choice of the lancet, the point of the arm to 
be selected, the age of the patient, &c, have all re- 



PUNCTURES. 365 

ceived much minute consideration in the different 
treatises on vaccination, but I think it is useless 
here to refer to them. Suffice it to say, that the 
sooner a child is vaccinated after one or two months, 
the better ; that the point of insertion of the deltoid 
muscle on that arm which is furthest from the nurse 
when the child is carried, is generally the most con- 
venient place for the operation : and that a plan that 
answers well is that just stated. 

The necessity for obtaining good matter, renders 
the preservation of it a point of considerable import- 
ance, and various plans have been employed for this 
object, and strenuously advocated by their especial 
supporters. Jenner received a drop of the matter, 
fresh from the pock, in a little hollow of a square 
piece of glass, which was then covered by another 
piece, and both luted together to keep out the 
air. Bretonneau, Friard, &c, of the French sur- 
geons, employed glass tubes of a fine calibre, with 
the same view ; but in this section of the United 
States, the matter is generally preserved in the 
dried state, and transmitted from one point of the 
country to another by mail : being pulverized and 
moistened with a drop of warm water when required 
for use. A simple plan of preserving the dried scab 
free from the air, is to make a little hollow in a cake 
of bees-wax: then soften the surface of this and 
another cake by heat, or scrape them perfectly 
smooth, and after placing the scab in the hole made 
for its reception, press the two cakes together, so as 
to form an air-tight box. I have vaccinated suc- 
cessfully in several instances with a scab four 
months old, preserved in this manner. 

The appearance of the arm, on the different days 
after the operation, is a matter of vital importance 
in forming an opinion of the results of the case ; and 
as an error of judgment here, by giving the patient 
a false security, might lead to sad consequences, I 



366 



PUNCTURES. 



shall not pretend to enter fully into its appearance, 
but refer the reader to the larger works. 

Figure 203 is an attempt to represent the proper 
appearance of the arm at the third, seventh, eighth, 
ninth, eleventh, and twelfth days after the operation. 
But it does so very imperfectly, owing to the absence 
of color. Those unacquainted with it must, there- 

Fig. 203. 



;' .:■■■■.:'■ 





•*1?% 



fore, consult some of the more finished plates on this 
subject, and only look to the cut as an outline. 

PUNCTURE OF THE LOBE OF THE EAR. 

The fashion of the day, and the taste of a numerous 
portion of the community, leading them to the use 
of rings in the lobe of the ear, it may occasionally 
happen that the practitioner will be called on to 
introduce them, although generally this is the busi- 
ness of the jewellers. As serious inconveniences have, 



PUNCTURES. 367 

however, frequently resulted from its performance 
by jewellers, &c, and as it occasionally affects very 
materially the comfort and health of the individual, 
it would perhaps be better were the profession to 
have a closer supervision of this little operation than 
is now generally the case. 

The perforation of the lobe of the ear may be ac- 
complished either by a large needle; by a small 
trocar and canula, like that used in hydrocele ; or by 
a small punch similar to that employed by saddlers. 

In either case, the lobe should be steadily pinched 
between the thumb and fore-finger for a few minutes 
previous to the operation, in order to diminish its 
sensibility ; then placing a piece of cork beneath 
the point to be perforated, force the needle or punch 
rapidly through the flesh, so as to make a free open- 
ing (Fig. 204). Immediately on withdrawing the 

Fig. 204. 




instrument, introduce a waxed thread, or a fine leaden 
ligature, or a piece of catgut, and move it daily 
through the perforation, in order to prevent its sides 
from adhering. Not unfrequently this movement 



368 PUNCTURES. 

produces so much irritation and discharge, as to con- 
stitute a regular seton, and is occasionally employed 
by the lower orders of society with this view, for the 
relief of sore eyes. But generally, after the lapse 
of ten days, the skin on the sides of the wound heals, 
and an opening is left through which the ear-ring is 
afterwards passed. I have several times known 
instances, when the needle alone was used, where 
subsequent union of the wound has required the 
repetition of the operation. The punch by removing 
the piece effectually prevents this, and is, therefore, 
the preferable instrument. 

The point selected for the perforation should 
always be sufficiently far from the extremity of the 
lobe to prevent the weight of the ring, or accidental 
catching of it by children, from tearing it out. When 
this happens, a marked deformity is produced, which, 
if the wound is not united soon after its production, 
will require on operation similar to that for hare-lip. 

PUNCTURE OF THE MEMBRANE OF THE TYM- 
PANUM, 

And that of the mastoid cells, might next be treated 
of; but they involve so many points of importance, as 
to exclude them from consideration in a volume like 
the present. 

PARACENTESIS ABDOMINIS, 

Or Tapping ; becomes necessary whenever (owing 
to some general disease) a large amount of serum 
accumulates in the peritoneal cavity of the abdomen, 
and by its distension impedes the respiration of the 
patient, or is otherwise productive of harm. As 
usually performed, a trocar and canula are employed, 
which, perforating the abdominal parietes, give exit 
to the fluid contained within it. The spot generally 
selected for the puncture is in, or near the linea 



PUNCTURES. 369 

alba, or two inches below the umbilicus : because we 
are here free from all danger of wounding important 
parts. The spot being chosen, place a broad band, 
slit at its extremities into six tails (like the bandage 
of Galen, p. 127), around the abdomen, with the 
tails crossed on the back of the patient, and direct 
two assistants to tighten it gradually as the fluid 
escapes, in order to force out the serum, and at the 
same time prevent the patient's fainting from the 
sudden loss of pressure on the abdominal vessels. 
The bladder being emptied, the surgeon should next 
remove a small piece of the bandage, immediately 
over the point which he proposes to perforate, and 
holding the trocar, as represented in Fig. 205, sud- 
denly force it and the canula into the abdomen. 
Holding the canula in its position, and withdrawing 

Fig. 205. 




the trocar, the fluid immediately escapes through the 
canula into the basin held in front of the patient. 
A tub or bucket should always be at hand, into which 
it may be emptied when required, as the amount of 
fluid is sometimes very large. After the evacuation 
of the liquid, the wound is to be closed by a strip of 
adhesive plaster; the bandage tied tightly in its 
place, and the patient put to bed and kept on strict 
diet. But as peritonitis frequently results from this 
operation, simple as it appears, the young practi- 
titioner is advised to be careful of his patient for 



370 PUNCTURES. 

several days afterwards, and especially cautious of 
his diagnosis in the case of females. As the cause 
of the disease is not affected by the operation, it 
generally happens that its repetition is almost inde- 
finite, though the subsequent performance does not 
differ in any respect from the one just described. 
The kind of trocar used is somewhat a matter of 
taste ; but I always prefer the flat instrument, as 
creating less pain and causing a smaller wound than 
that which is rounded. In either case, particular 
attention should be given to cleansing the trocars 
after the operation, as the rusting of the trocar in 
the canula frequently renders it difficult to withdraw 
the former. In one instance that came under my 
notice, the instrument was driven into the abdomen, 
and the operator obliged to withdraw it, owing to 
his inability to free the trocar. A little oil after 
using it, or its examination previous to the operation, 
would have saved him this mortification. 



PUNCTURE OF HYDROCELE. 

The evacuation of serum from the Tunica Vagi- 
nalis Testis, is generally produced by means similar 
to those just detailed. As the occurrence of hydro- 
cele is by no means rare, as the operation is simple, 
and one that almost any physician can perform with- 
out risk or even any great trouble, I would recom- 
mend it to a more general attention on the part of 
medical practitioners, having seen much suffering 
caused by physicians refusing to tap these tumours. 
When satisfied of the existence of a hydrocele, let 
the operator seize the scrotum with his left hand, 
and squeeze it firmly from above downwards, as re- 
presented in Fig. 206. Then taking a small trocar 
and canula in the right hand, as shown in the figure, 
plunge it into the tumour, directing it obliquely up- 
wards, in order to avoid injuring the testicle, which, 



PUNCTURES. 371 

under ordinary circumstances, is found at the pos- 

Fig. 206. 




terior inferior portion of the swelling. Fig. 207 

Fig. 207. 




shows, in outline, the effect of puncturing a hydrocele 



372 PUNCTURES. 

directly backwards, the trocar if continued being 
likely to pass directly into the testicle. The dotted 
line shows the proper course of the puncture. Should 
a trocar not be at hand, a thumb lancet may be used 
in the same way, and the wound kept open by a probe 
until the fluid is evacuated. But the trocar is far 
preferable, as it avoids the risk resulting from the 
escape of the liquid into the cellular tissue of the 
scrotum. The operation is, however, merely pallia- 
tive, unless inflammation of the serous cavity be 
afterwards induced. 

Should a practitioner be so situated as to render 
it obligatory on him to perforin a radical cure, he 
must, after evacuating the fluid, introduce either a 
seton or stimulating injection, according to circum- 
stances. But as I do not wish to recommend the 
the radical operation to every practitioner, the 
reader is referred to the works on Surgery for 
further details. 

The Diagnosis of the diseases concerned in these 
operations is, I think, decidedly the most important 
point connected with them, and I would, therefore, 
invite attention to the means usually found effectual, 
in deciding it. In Ascites, the previous history of 
the case : the probability of pregnancy : disorder of 
the liver, or heart, or kidney, or some other organ, 
will do much towards preventing mistakes. Yet 
even then, nothing but the absolute certainty of the 
effusion should render the operation justifiable. This 
may generally be proved beyond a doubt by placing 
one hand, fully expanded, upon one side of the belly, 
and then tapping lightly and quickly, with the points 
of the fingers of the other hand, on the opposite side. 
The force of the tap acting upon the fluid will drive 
it to the opposite hand, and a distinct succussion or 
fluctuation be perceived under the one first extended 
on the abdomen. Should flatus be present, the tym- 



PUNCTURES. 373 

panitic resonance will indicate it, but there will not 
be the wave-like sensation given to the hand, by tap- 
ping the fingers on the side of the belly, which is 
always felt if there be a sufficient amount of effusion 
to justify its evacuation. 

In Hydrocele, the most certain test of its exist- 
ence is the following : Place the patient in a dark 
room, and then grasping the scrotum tightly, hold a 
lighted candle as near as possible to the scrotum, 
without burning the patient. The liquid, if serum, 
being perfectly transparent, the testicle will be 
seen as a dark mass, wherever it may be situated, 
and of course avoided in the puncture. This will 
also be found a most useful test in diagnosticating 
hernia, sarcocele, or hematocele, as the appearances 
of these are entirely different, being darker than that 
of hydrocele. This testing the existence of hydrocele 
by a light is so simple, that every practitioner should 
be able to diagnosticate an effusion into the Tunica 
Vaginalis under ordinary circumstances ; and if prac- 
tised more frequently, would prevent the evils which 
occasionally result from the patient being directed 
to wear a truss, &c, in consequence of the prac- 
titioner's belief in the existence of hernia. 

KANULA, 

Or an accumulation of the salivary secretion in the 
sublingual ducts, requires an operation not only to 
remove the fluid, but also to guard against the per- 
manent closure of the opening made. This operation 
may be performed either with a thumb lancet, bis- 
toury, or trocar, by elevating the patient's tongue, 
and pushing the instrument directly into the tumour, 
parallel with the alveolar processes of the lower jaw. 
After the escape of its contents, it is then necessary 
to introduce something into the wound to keep it 
open. A simple instrument, for this purpose (analo- 
gous to that of Dupuytren), may be made by bencl- 
32 



374 PUNCTURES. 

ing a piece of fine, stiff wire, two inches long, upon 
itself, so as to give it the shape of the letter V, and 
introducing the point of the V into the cyst, the 
elasticity of the wire will be sufficient to dilate the 
opening until the chance of its union is past. 

Breschet and others have thought that Ranula, 
instead of being an obstruction of the duct, was 
caused by regular cysts. Be this as it may, the 
operation of excision of a portion of the surface 
usually suffices for their cure. 

OF SALIVARY CONCRETIONS 

Depositions of earthy matter, chiefly phosphate 
of lime, are occasionally found in the openings of 
the salivary ducts, and when of any size, give rise 
to considerable inconvenience by impeding the enun- 
ciation and deglutition of the patient. When large, 
they may be readily removed by an incision on the 
parietes of the duct, and seizing them with forceps ; 
but when small, they are not so easily caught, as 
they slip back in the line of the duct. Under these 
circumstances, it has been recommended to cause 
the patient to chew any substance likely to excite 
the flow of saliva, after making 
Fig. 208. a slight incision ; the escape 

of the fluid generally bringing 
away the concretion. A figure 
of a salivary concretion, taken 
from Liston, is represented in 
the cut, and gives a good idea 
of their shape and size, though occasionally much 
larger. I have seen one which was so large as to 
fill up the space beneath the tongue, and resembles 
a large Ranula, except in the colour and consistence 
of the tumour. 

PUNCTURING OF ABSCESSES. 
The existence of pus under certain tissues, espe- 




PUNCTURES. 375 

cially under fascia, renders its detection and early 
evacuation often a matter of considerable import- 
ance, in order to prevent its extension, and the 
consequent injury of surrounding parts. To the 
young surgeon, and often to those more advanced, 
few things are more deceptive, and occasion greater 
doubt as to the evidences of its existence than these 
accumulations of matter. In examining a deep- 
seated part where pus is suspected to exist, even 
when care is taken, deception is apt to ensue, unless 
pressure is made in the proper manner, as may be 
readily proved by the following simple experiment : 
Place the muscles of the thigh or leg in a state of 
relaxation, and press on any given point with two 
fingers of each hand, alternately ; the sensation of 
fluctuation will be so distinct as to deceive any one 
unacquainted with the fact. Now, if under the sus- 
picion of the existence of pus, pressure is made in 
the same way, an operation for its evacuation might 
be urged, and the practitioner mortified in not finding 
the matter, of whose existence he felt so certain. 

Previous, then, to opening an abscess, render the 
fluctuation apparent by the following means : Press 
one or two fingers of one hand firmly on the side of 
the point suspected, and keep them thus firmly fixed: 
whilst pressure is first made and then removed, by the 
application of the fingers of the other hand. If mat- 
ter exists, it will be forced against the fingers first 
applied, and the fluctuation rendered certain ; whilst, 
if it does not, the deceptive movement of the muscles 
of the part, first referred to, will be prevented. 

The existence of pus being positively established, 
its evacuation by puncture may be performed either 
with a sharp-pointed bistoury, or abscess-lancet, by 
plunging it into the collection at right angles to its 
surface, and enlarging the opening by cutting out- 
wards and upwards; or by introducing it perpendi- 
cularly to the surface until it enters the cavity (as 



376 



PUNCTURES. 



shown by the want of resistance), and then cutting 
outwards. Or, if the abscess is superficial, the bis- 
toury may be thrust through it, and a free opening 
made simply by elevating the handle, and cutting 
from within outwards, as in Fig. 209. The subsequent 
treatment will depend upon the circumstances of the 
case. 

Of the use of Potassa for the evacuation of ab- 
scesses, I have nothing to say ; preferring the knife 
for this purpose. 

Fig. 209. 




In large deep-seated abscesses or tumours, the con- 
tents of which are doubtful, the introduction of a 
grooved needle, or one somewhat coarser than those 
used in Acupuncturation, will frequently enable us to 
decide on their contents, and save much trouble to 
Tboth patient and practitioner. 



CHAPTER V. 

OPERATIONS FOR ARRESTING HEMORRHAGE. 

The existence of hemorrhage generally creates so 
much alarm, and actually involves so much responsi- 
bility, that little need be said, in reference to the im- 
portance of a proper plan of treatment; common sense 
alone dictating the necessity of arresting it at an early 
period, lest its amount debilitate or affect the life of 
the patient. 

Of the various operations required for this purpose, 
the simplest is undoubtedly that of Pressure, which, 
in common with the other means required, I shall 
treat of, without further reference to its physiologi- 
cal effect, than the simple statement that, when long- 
continued, it favours the formation of a clot, in and 
around the divided vessel. 

PRESSURE FOR ARRESTING HEMORRHAGE 

Maybe applied either by the Fingers, by Compresses 
and Bandages, by the Spanish Windlass, or by the 
Tourniquet. 

In the first, the application of the force will de- 
pend upon the position of the part and the circum- 
stances of the case, and as the hemorrhage from the 
arteries is that which is of the most importance, I shall 
confine myself to it. When blood escapes from an 
artery, it does so in jets, corresponding with the pul- 
sations of the heart, and is of a bright red colour. 
This jet generally shows the position of the injured 
vessel, and the origin of the hemorrhage, if superfi- 
cially seated. The introduction of the point of the 
finger to the bleeding vessel, and pressure at that 
32* 



378 OPERATIONS FOR 

point, will therefore generally suffice to arrest it 
until more powerful means can be obtained. But if 
the wounded vessel is deep-seated, and the point 
wounded cannot be thus seized on, pressure must be 
made upon the artery at some point of its course, 
above the seat of injury ; that is, between the heart 
and the wound. 

This pressure may be made either with the points 
of three or four fingers, closely placed together ; or 
by the thumb. If the Fingers are used, place their 
points close together in the course of the artery, and 
seize the opposite side of the limb with the thumb, so 
as to steady them (Fig. 210), or place the point of 

Fig. 210. 




the thumb upon the vessel, and the fingers on the 
opposite side of the limb, and when the pressure 
fatigues the thumb, place that of the other hand on 
top of the first, and thus relieve it (Fig. 211). But 
even when possessed of great powers of endurance, 
few persons can continue this sort of effort except 
for a few minutes, and these means are therefore only 
available for a limited time, as the fatigue soon re- 
quires a release of the hands employed. 



ARRESTING HEMORRHAGE. 



379 



When it is absolutely necessary to employ pressure 
for a long period, as upon the Sub-Clavian or Iliac 
Arteries, a large key, wrapped around with bandage, 
so as to prevent the handle from injuring the soft 
parts, will prove an excellent instrument, and far 
preferable to the fingers or thumb, not only on ac- 

Fig. 211. 




count of its adaptation to the shape of the part, but 
also because the pressure may thus be continued for 
a greater length of time. 

The French surgeons frequently employ pressure 
to arrest the circulation in a limb during amputations ; 
but as its success depends upon the strength and 
address of the assistant, I would not advise its em- 
ployment, as a general practice, where a tourniquet 
can be had. 

The use of compresses and bandages for this pur- 
pose, has been already referred to (page 41), and 
require no addition to what was there mentioned. 

THE SPANISH WINDLASS 

Is an excellent every-day instrument, of considera- 



380 OPERATIONS FOR 

ble power, and yet of great simplicity. It may be 
made on the spur of the moment, by twisting a pocket- 
handkerchief, and tying a knot in its middle. Then 
placing the knot over the vessel, tie the ends of the 
handkerchief loosely on the opposite side of the limb : 

Fig. 212. 




and introducing a stick into the loop formed by the 
ends, twist the handkerchief by turning the stick, as 
represented in the cut (Fig. 212). 

THE TOURNIQUET OF PETIT, 

Or the tourniquet of the amputating case, being the 
one most generally employed in the United States, 
should be applied as follows : Place a compress over 
the vessel, and surround the limb with two or three 
turns of a bandage, so as to bind the compress on 
the part, and thus protect the skin from being chafed 
by the strap of the instrument. Next place the 
plates, closely screwed together, directly over the 
compress, and strap it firmly in its place, without 
any reference to the position of the buckle, as the 
plates, and not the buckle, are to make the pres- 
sure. On screwing the instrument, the compress will 
be firmly forced on the vessel, and the circulation 
arrested, in consequence of the separation of the plates 
by the action of the screw, the lower part of this 
being made to bear directly on the compress. Many 



ARRESTING HEMORRHAGE. 



381 



surgeons, however, advise a different plan from this, 
preferring to place the pad of the buckle over the 
vessel or the plates on one side of the limb, and a 
compress under the strap on the side next to the 
artery, believing that the strain upon the pad under 
the strap will make more decided pressure ; but the 
method just stated embraces, I think, the intention 
of the inventor, and is free from the objection of many 
of the accidents likely to arise from the use of the 

Fig. 213. 




instrument in other ways. In amputations, the limb 
should be elevated a few minutes previous to the ap- 
plication of the tourniquet, in order to empty the 
veins, and save the loss of blood which otherwise fol- 
lows the division of these vessels. All such means 
of arresting hemorrhage are, however, temporary; 
and I would caution the young practitioner against 
relying on pressure for more than an hour, or an 
hour and a-half : as the arrest of the circulation in 
the limb for a greater length of time might, in some 
cases, produce mortification. I once saw a thigh 
amputated on account of a slight incised wound of 
the knee ; which opening one of the small articular 



382 OPERATIONS FOR 

arteries of the part, gave rise to hemorrhage, and 
which an ignorant practitioner attempted to arrest 
by the use of a tourniquet applied to the femoral 
artery, and kept there, notwithstanding the suffer- 
ings of the patient, for two days ; when mortification 
became apparent. The evils resulting from the con- 
tinued application of the tourniquet of Petit, have 
rendered a spring tourniquet, or one which only 
presses on two points of the limb, a favourite instru- 
ment with many surgeons. In the treatment of aneu- 
risms by compression, especially since the publica- 
tion of the excellent papers of Mr. Bellingham, of 
Dublin, this instrument has proved very useful. 
Fig. 214 explains it at a glance. One pad rests on 
the point opposite the vessel, and the other is pressed 
upon the artery, by means of the screw 
Fi( J- 214. attached to it. 

The success which has attended the 
treatment of aneurism by this instru- 
ment, and its simplicity, may well recom- 
mend it to the attention of all, but espe- 
cially of those practitioners who are un- 
willing to attempt the ligature of the 
vessel. 

Whenever an aneurism exists in an 
extremity, Mr. Bellingham directs the 
use of two such compressors, as follows : 
Suppose an aneurismal tumour of the 
Popliteal Artery ; Place the patient 
in bed and apply the compressors to the femoral 
artery, one in its course on the middle of the 
thigh, the other nearer the groin. Screw up either 
one, so as to compress the vessel and diminish 
the circulation through it ; but do not apply it so 
firmly as to stop it entirely. Then, when the patient 
complains of the pressure, screw up the other com- 
pressor, and relax the first. With an intelligent 
patient the treatment may be left to himself. The 
object of the pressure is to favour the formation of 




ARRESTING HEMORRHAGE. 383 

a clot in the aneurismal sac, in consequence of the 
sluggishness of the current of blood which passes 
through it. A more detailed account will be found 
in Braithwaite's Retrospect, Part 13th, 1846, and in 
Rankin. 

Whenever it is necessary, in cases of wounds, 
or after operations, to arrest the flow of blood 
permanently, the ligature or torsion must be 
resorted to; and as this, in important operations, 
falls more or less upon the assistants, especially 
when situated in hospitals, or in the navy or 
army, it will become their duty to prepare both 
the sponges and ligatures which are required for 
this purpose. The usefulness of both depends in a 
great degree on their quality; and I therefore sub- 
join the method in which I have generally prepared 
them. In order to obtain a good sponge, the assist- 
ant should select a soft, elastic, round piece, not 
smaller than a peach, and not larger than the fist. 
If too large it will be clumsy, and pressing on a large 
surface, when applied, cause unnecessary pain. As 
found in the shops, even the best sponge contains 
more or less calcareous matter, which renders 
it unfit for surgical purposes. The first step in 
its preparations is, therefore, to pound it whilst dry, 
and then wash it thoroughly in water to remove the 
loose sand. Next, place it in a non-metallic basin , con- 
taining enough muriatic acid and water to cover each 
piece, varying the strength of the mixture according 
to the quality of the sponge. But even the finest 
sponge will bear it without any injury to its tex- 
ture, in the proportion of one part of the acid to 
sixteen parts of water. After remaining in this 
mixture about two hours, or until no hard particles 
can be felt, the sponge should be thoroughly washed 
in fresh water, and then allowed to soak about one 
hour in a solution of carbonate of soda, one ounce to 
the quart, when being again thoroughly washed 
and soaked in water, which is frequently changed, it 



384 OPERATIONS FOR 

will be ready for use. Sponge of a good quality for 
surgical purposes should be soft, and so elastic as to 
be able to recover its shape when moist and com- 
pressed in the hands. Its cells, therefore, should 
not be finer than mustard seed, as it is then apt to 
clog with the blood, and become flabby or cotton-like. 

The whiteness of sponge, further than that afforded 
by the above method of preparing it, is of no conse- 
quence, the chlorine with which it is usually bleached 
tending rather to impair its usefulness by destroying 
its tenacity. 

A first-rate piece of sponge is to an operating sur- 
geon a valuable article, and difficult to obtain under 
ordinary circumstances, unless he prepares it for him- 
self, and this he can readily do by pursuing the course 
just stated. 

In applying a sponge to cleanse a bleeding surface, 
the assistant should place it boldly and quickly on 
the part, so as to compress its cells, and then as it 
expands in his fingers remove it, wash and reapply 
it by a rapid movement. The water used to wash 
the sponges during an operation, should not be of a 
higher temperature than 65°, under ordinary circum- 
stances, though occasionally warm water may be re- 
quired. A good piece of sponge attached to a liga- 
ture, thrust into a deep wound, and there left for 
forty-eight hours, will often arrest that troublesome 
hemorrhage in which the blood seems to come from 
a number of points, and not any one vessel. 

Next after sponges the assistant should look to the 

LIGATURES. 

The material for ligatures has, for a long period, 
engaged the especial attention of surgeons, and an 
almost indefinite variety of substances have been re- 
commended as especially fitted, by their unirritating 
character, to be introduced and left within the flesh. 
As nearly all ligatures eventually come away by sup- 
puration, it is of little consequence what material 



ARRESTING HEMORRHAGE. 385 

they are made of, provided it is strong and sufficiently 
thick to prevent its cutting through the coats of the 
vessel too rapidly. Generally, the internal and middle 
coat of the artery are divided by the ligature, and 
the external coat ulcerates through ; but in cases of 
disease, as ossification, &c, all the coats will yield 
quickly to a fine ligature. I, therefore, generally 
prefer a round ligature made of saddler's white silk. 
Of this, a single strand, well waxed, is sufficiently thick 
for the smaller arteries, as the coronary, &c. : two 
strands for vessels of the size of the Radial and Ulnar ; 
three strands for the Femoral and Brachial ; and four 
strands for the Iliac and Sub-Clavian. 

In preparing these ligatures let each strand of silk 
be well waxed, and then let two assistants lay them 
together and twist them in opposite directions until 
firmly twisted, keeping the ligature stretched until 
the strands thus united are again lightly waxed. 
Then attaching each end of the ligature to a nail, 
allow it to remain stretched for several hours, other- 
wise it will be likely to untwist itself. Ligatures, as 
thus prepared, should next be cut into pieces about 
ten inches long, and laid side by side in a fold of 
moderately-stiff paper, wide enough to hold eighteen 
or twenty-four pieces. This paper being turned over 
at one end to the depth of an inch, will preserve the 
parallelism of the ligatures, and enable the assistant 
to draw out one at a time, without deranging and 
entangling the remainder. 

In order to apply a ligature to a divided vessel, it 
is necessary to pick out the artery from the surround- 
ing parts, and this may be effected either by the 
tenaculum or forceps. 

The Tenaculum is the instrument generally pre- 
ferred. It is used by sticking its point into the ves- 
sel and drawing it out from the wound, until the loop 
of the ligature can be tied over it. But if Forceps 
are desired, they may be employed as follows : Seize 
33 



386 



OPERATIONS FOR 



the vessel with a pair of Liston's, which I think de- 
cidedly the best for this purpose, and draw out the 
artery as before. Where the forceps, as in Fig. 215, 
are fitted with teeth, and have a spring in the handle, 

Fig. 215. 




they will retain their hold of the vessel, even when 
allowed to hang, until the surgeon places the ligature, 
even without the aid of an assistant. The firmness 
of their hold has given them the name of bull-dogs. 

In tieing a ligature, one loop should be thrown 
around the extremity of the vessel, beneath the in- 
strument, and tied. Then forming a second knot on 
the first tie, draw it tight, by using the thumbs in 
the way that a shoemaker draws his wax-end, and 
not by pulling it with the fingers, as a school boy 
ties his shoes. 

Various knots have been recommended for the 
purpose of retaining the ligature on the vessel. 
Among the most common of these are those known 
as the surgeon's and the sailor's knot. 

THE SURGEON'S KNOT 

Is made by passing either end of a ligature twice 
Fig. 216. 




around the other, and drawing it tight. The figure 
(216) represents the left end, or that taken from the 



ARRESTING HEMORRHAGE. 387 

right hand, turned twice around the other, in order 
to form the knot, but not drawn tight. These turns, 
however, form a flat knot, like a figure of 8, and do 
not compress the vessel as tightly as the sailor's knot. 
It is therefore but little used at present. 

THE SAILOR'S KNOT, 

Like the clove-hitch, is one, that when drawn tight, 
will hold very firmly all that is included within it. 
Owing, also, to the firm compression that it exercises 
on the vessel, it is the one most frequently employed, 
as it divides the internal and middle coats more 
rapidly. In order to form it, tie a knot as in the 
lower loop of Fig. 217, and then a second or third 
on top of that, drawing each knot firmly with the 
thumb in the manner just referred to. Or, if the 
figure is not sufficiently 
plain, practise the turns Fi 9- 21 ?- 

as follows; take a turn 
of the ligature around the 
finger, passing from left 
to right, and bringing the 
right hand end around 
the left ; knot it firmly ; 
then bringing the left 
hand end around the right, reverse the first turns, 
and again knot it firmly. Should any doubt exist as 
to its firmness, a third or fourth knot may be formed 
on top of these, by the same turns : going first from 
left to right, then from right to left ; and afterwards 
continuing the turns from right to left, as required. 

In the application of ligatures to arteries in exten- 
sive wounds, one end should generally be cut off 
within a quarter of an inch of the knot, and the other 
brought out of an angle of the wound, in order to faci- 
litate its removal. Occasionally, both ends are cut 
off, and the knot left to come away with the dis- 
charge ; but the first plan is preferable for many 
reasons. 




388 OPERATIONS FOR 

TOKSION, 

Or twisting of the artery, arrests hemorrhage on the 
same principles as the ligature, so far as the coats 
of the vessel are concerned : viz., by lacerating the 
internal and middle coat. It is performed by seizing 
the end of the vessel with a pair of forceps which 
are made to close with a catch, and then rotating the 
instrument in the fingers, the artery is twisted upon 
itself. Although a favourite method with the French 
surgeons, and answering tolerably well for small 
vessels during extensive operations (as it saves the 
time required for the application of ligatures), yet 
it cannot be permanently relied on ; and I would 
not recommend it except in the cases referred to, 
where ligatures may be subsequently applied if de- 
sired : secondary hemorrhage not unfrequently re- 
sulting from its use. 

If the hemorrhage comes from a deep-seated ves- 
sel, it will frequently be necessary to cut down in its 
course, and throw a ligature by tenacula, or other 
instruments, around the artery, above the seat of 
injury. These operations are, however, generally 
so important, and depend so entirely upon the ana- 
tomical knowledge of the operator, that they would 
be misplaced if treated of here. 

Besides that just considered, hemorrhage not un- 
frequently occurs from different cavities of the body, 
where, instead of one main vessel being the source, 
the blood comes from numerous small ones by a 
general oosing. Under these circumstances, styp- 
tics, or the introduction of foreign bodies into the 
part, in order either to make pressure or assist the 
formation of the clot, will be found necessary to 
arrest it. 

Among Styptics, the direct application of the 
Nitrate of Silver to the bleeding surface will, I 
think, prove the best; or we may use the Tinctura 



ARRESTING HEMORRHAGE. 



389 



Ferri Chloridi, or Powdered Galls, or Sulphate of 
Iron, or Copper, or Zinc, or Acetate of Lead, or 
Alum, or Agaric, Matico, or Powdered Ice, or the 
Potential Cautery, &c, &c. 

But where the bleeding cannot be thus stopped, 
plugging up the part, in order to assist in the forma- 
tion of a clot, becomes necessary ; the peculiarity of 
the tampon being modified by the cavity to be filled. 

PLUGGING OF THE NOSTRILS. 

In order to arrest excessive hemorrhage from the 
nostrils, it is necessary to introduce a foreign body 
not only into the nose in front, but also into the 
posterior nares. This may be best accomplished by 
an instrument that should be found in all pocket- 
cases, viz., Bellocque's canula, armed with its stylet 
and ligatures- In using it, pass the point of the 

Fig. 218. 




canula along the floor of the nostril till it reaches 
the soft palate. Then pushing forward the stylet 
until it comes into the front of the mouth, attach a 
33* 



390 OPERATIONS FOR 

ligature in the eye of the instrument ; then fasten a 
small piece of lint, spread with cerate or oil, or of 
moistened sponge not more than an inch long (Fig. 
E, 218), to the ligature; and drawing the stylet back 
into the canula, withdraw the latter and fasten 
the plug in the posterior nares by pulling firmly on 
the ligature, or on one portion of the double-thread 
which was attached to it : thus leaving one portion 
of the thread in the mouth, the other in the nostril. 
On stuffing the front of the nostril with any soft sub- 
stance the whole passage will be firmly closed, and 
it only remains to fasten the thread coming from the 
mouth by adhesive plaster : or to tie the end from 
the nose and that from the mouth loosely together, 
to complete the operation. If the hemorrhage has 
been excessive, the plugs may remain three days, or 
at all events until a clot forms on the bleeding sur- 
face. When it is wished to remove them, pick out 
that in the front of the nostril, and introducing a 
probe, push the posterior one into the throat : or 
draw upon the lower thread, by which it may be 
drawn into the throat and mouth. This thread is that 
which was left attached to the plug. 

If Bellocque's canula is not at hand, we may use 
a catheter with a double ligature fastened in its eye. 
This being passed through the nostril until the thread 
shows itself in the throat, draw the ligature out of the 
mouth by a pair of forceps : when, after attaching the 
lint to it, the whole may be again drawn through the 
posterior nares, and the thread confined as before. 
Sponge being softer and more absorbent than lint 
would be preferable as a plug, were it not that it is 
apt to become very firmly wedged in the posterior 
nares in consequence of its expansion. 

HEMORRHAGE FROM THE RECTUM 

Occasionally gives rise to most serious results, and 
requires to be arrested immediately, in order to pre- 



ARRESTING HEMORRHAGE. 391 

serve life. As in most cases it is the result of some 
operation upon the part, the most certain means of 
arresting it is to employ a rectum speculum, and if 
the vessel can he seen, to tie it. But when this is 
not possible, resort may be had to compression by 
means of cotton or lint stuffud into a bladder like a 
sausage, and forced into the gut. Cold water or 
powdered ice may may also be thus employed, pro- 
vided caution is used as to the effects of the cold on 
the system generally. The use of anything, however, 
thus introduced into the rectum, is accompanied by 
great inconvenience and difficulty of retention, from 
the expulsive efforts that it induces. In such cases, 
resort may be had to the actual cautery, after the 
the plan of Dupuytren ; or where the bowel is kept 
distended with blood, the introduction of the nozle 
of a syringe, or a catheter, into the gut, will probably 
prove useful by keeping it empty, and thus permitting 
the closer contraction of the parts about the bleeding 
vessel. 

HEMORRHAGE FROM THE BLADDER 

Is not of frequent occurrence, and still less frequently 
of such an extent as to require direct interference. 
Should it however occur, the principle to be observed 
would be, to keep the bladder perfectly empty by the 
use of the catheter, and employ cold externally or 
even introduced to the inside of the bladder itself, 
by means of a syringe and catheter. 



CHAPTER VI. 

OF WOUNDS. 

These, if of a simple kind, and not involving parts 
of vital importance, generally require but little con- 
stitutional treatment : the attention of the practitioner 
being mainly confined to arresting the hemorrhage, 
removing foreign matter, and promoting the union 
of the divided surfaces. Of the first I have already 
spoken under its appropriate heading ; the second 
will be treated of hereafter, and the third indication, 
or the union of the divided edges, now requires notice. 
Coaptation of wounds may be accomplished by 
four means, that is by Sutures, by Adhesive Straps, 
by Bandages, as before stated, or by Collodion. 

SUTURES. 

This is the name given to stitches which are in- 
tended to approximate the sides of wounds, especially 
when occurring in parts that are naturally loose and 
moveable. They are of five different kinds, as at 
present recognised, viz. : the Interrupted, Continued, 
Twisted, Quilled, and Dry. 

THE INTERRUPTED SUTURE 

Is the one most frequently employed, and is made 
by introducing a needle similar to either of those in 
Fig. 219, armed with a simple ligature, through one 
lip of the wound from without inwards, and through 
the other lip from within outwards, at such a distance 
from its edges as will prevent the stitches cutting 
out too soon. Then drawing or pressing the sides of 



— 



WOUNDS. 



393 



the wound together, tie the ends of the ligature moder- 
ately tight in a double sailor's knot (Fig. 217), taking 
care not to put too much strain upon the parts, lest 
the thread cut through the skin. In using the needle, 

Fig. 219. 




carry it deep enough to obtain a firm hold, but not 
so deep as to include the tendons or fascia : making 
the requisite number of stitches at about an inch 
apart, and supporting them, if necessary, with a few 

Fig. 220. 




adhesive strips or a bandage (Fig. 220, A). When, 
after the lapse of two or three days, it is wished to 
remove them, seize the knot with a pair of fine for- 
ceps, and cutting the thread, withdraw it carefully 
from the part : leaving the adhesive plaster for a day 
or two longer, in order to secure the union. When 
sutures are allowed to remain a longer time than this, 



394 wounds. 

ulceration is induced, and this will eventually remove 
them, but leaves a ragged sore, and a more marked 
cicatrix. As all the advantages of their use are ob- 
tained in forty- eight or seventy- two hours, they are 
generally cut out at the end of the second or third 
day. 

Sutures are not as much employed as they might 
be, on account of the horror that patient's entertain 
of the use of a needle in the flesh, and also of preju- 
dice on the part of some surgeons. But the more 
perfect adhesion gained where parts are moveable, 
and the greater certainty of the continued approxi- 
mation of the edges by these means, are strong in- 
ducements to their employment ; and I must confess 
a predilection for them to a greater degree than 
that of most other practitioners. 

THE CONTINUED SUTURE, 

Also called the Glover's Suture, is made by passing 
a needle and thread through and through the integu- 
ments as in ordinary sewing (Fig. 220, B). It is. 
however, seldom employed, except in wounds of the 
intestines, and in sewing up dead bodies, after post- 
mortem examinations. 

Another mode of making the continued suture, and 
one that answers very well where it is desirable to 

Fig. 221. 




make considerable traction on the threads, is that 
represented in Figure 221. The thread is passed 



wounds. 395 

as represented in the cut, and as it includes more or 
less of the parts on the side of the wound, draws 
them together with almost as much firmness as the 
quilled suture. Like this, however, it is now but little 
used,- but might be more frequently employed, with 
advantage, in wounds of the thigh, buttock, &c. 

THE TWISTED, OR $ ARE-LIP SUTURE, 

Is made by introducing several pins through the 
sides of a wound, at a depth sufficient to hold firmly, 
and then twisting a ligature around each extremity 
in the shape of a figure 8 (Fig. 220, C). In angular 
wounds, the first pin should be placed at the lowest 
angle, in order to ensure a regular adaptation of 
parts, and then the others introduced at equal dis- 
tances, say half an inch apart. After forty-eight 
hours, the pins should be withdrawn by the forceps, 
with a slight rotatory motion ; but the ligatures may 
be left until loosened by the discharge, or subsequent 
dressings. 

In the selection of pins there is much useless par- 
ticularity ; some surgeons directing silver pins with 
moveable steel points, in order that by their removal 
they may prevent the points injuring the adjacent 
parts ; others advising round, and some square points. 
But one great objection to these moveable points is, 
that if it is necessary to withdraw the pin a little, in 
order to vary its point of exit, the steel point is 
liable to be left in the flesh. Silver, also, has no ad- 
vantage I think over other substances ; and the 
common cambric needles with sealing-wax heads, or 
a good stout pin of the ordinary kind will answer 
equally as well: as the point may be surrounded 
with a little pellet of wax after it is introduced, or 
may be cut off by a pair of bone-nippers. 

A very good hare-lip pin may be made of steel 
wire, cut to any length, and brought to a triangular 
point at one end, by a few touches of the file. I 
seldom employ any others. 



396 wounds. 

In placing pins after the operation for hare-lip, 
considerable advantage may be gained by passing a 
fine ligature through each free angle of the flaps, 
previous to introducing the pins. By means of this 
ligature it is easy to bring the edges to the same 
level, and guard against the central depression or 
indentation which so often results ; after the pins 
are placed, this ligature is to be removed. I have 
often noticed the difference in the result of the 
operations of the French and American surgeons in 
this respect, and believe the success of the former to 
be owing to this plan of operating. 

THE QUILLED SUTURE 

Is intended for the union of deep-seated parts ; but 
as its place can be well supplied by a compress and 
strips, or by a uniting bandage, it is not at present 
much employed. It is made by passing a number of 

Fig. 222. 




double ligatures through the sides of the wound, 
and placing a little roll, or quill, or catheter, in the 
loop on one side and tieing the opposite ends of the 
ligature around another quill (Fig. 222). The liga- 
tures acting on the quills, instead of directly on 
the skin, are enabled to force the parts more closely 
together, without the risk of cutting through the 
integuments. 



WOUNDS. 



397 



THE DRY SUTURE 

Is made by fastening strips of adhesive plaster on 
each side of a wound, and then approximating 
them, by tieing together the ligatures introduced 

Fig. 223. 




into the strips of each side (Fig. 223). The dif- 
ference between this and the interrupted suture is, 
in the former being passed through the adhesive 
strips instead of through the integuments, as in the 
latter. 

A narrow piece of muslin, made to adhere to the 
skin by the use of Collodion, will also answer ex- 
tremely well. 
34 



CHAPTER VII. 

CATHETERISM. 

The introduction of tubes into the different passages 
of the body requires, in the first place, an accurate 
knowledge of the anatomical relations of the parts, 
and then some skill in the manipulation of the in- 
struments. In most cases, the movements should 
be slow and gentle, rather than rapid and violent, 
and in the use of the instruments, especially as ap- 
plied to the urethra, the object should be rather to 
introduce them without attracting the patient's 
attention, than to take him, as it were, by storm : 
as I have occasionally seen done, by the would-be 
dexterous operators. 

CATHETERISM OF THE URETHRA. 

The passage in which catheters are most frequently 
employed, is undoubtedly the urethra. For this pur- 
pose the tubes are made of various shapes, sizes, 
and substance ; but to one acquainted with the ana- 
tomy of the part, their shape is a matter of little 

Fig. 224. 




importance, a straight instrument passing quite as 
readily as a curved one. Generally, however, the 



CATHETERISM. 



399 



male catheter is bent to the curve represented in 
Fig. 224 ; whether made of silver, caoutchouc cloth, 
or gutta percha, with an eye on each side, or with 
several perforations, according to the taste of the 
operator. When the gum-elastic catheter is employed, 
a wire or stylet is generally required to be intro- 
duced into it, in order to give the requisite stiffness, 
and prevent its yielding to any temporary obstruc- 

Fig. 225. 




tion that may be met with. In introducing a cathe- 
ter, the simplest proceeding will be found to be the 
following : 

Place the patient on his back, with the limbs and 
shoulders slightly elevated, in order to relax the 



400 CATHETERISM. 

abdominal muscles. Then, having oiled the instru 
ment, take it in the right hand, by its mouth, and 
seizing the head of the penis between the finger and 
thumb of the left hand, so as to hold it perpendicu- 
larly to the patient's abdomen, place the catheter in 
the orifice of the urethra, and, whilst the patient's 
attention is engaged by conversation or otherwise, 
slide the point of the instrument gently down the ure- 
thra until it reaches the arch of the pubis, or can be 
felt deep in the perineum. Then gently depress the 
penis and catheter until the instrument is parallel 
with the patient's thighs, when the point will sud- 
denly slip over the triangular ligament and enter 
the bladder, as is at once shown by the escape of 
urine. The cut (Fig. 225) represents the position 
of the instrument at the moment when it is to be 
laid parallel with the thighs. Should the patient 
strain, or resist the operation, rest for a moment, 
and passing the left hand gently over the abdomen, 
so as to promote relaxation of its muscles, try again 
to keep him in conversation, so as to prevent his hold- 
ing his breath. But should there be no stricture of 
the urethra, little difficulty need be anticipated in 
the introduction of the instrument. 

Various other plans of catheterism have been 
recommended, either for the surgeon's convenience, 
or to enable him to astonish the by-standers ; but 
the above plan embraces the simplest means, and 
is the practice that I learned when following the 
practice of M. Civiale, a gentleman who is probably 
the most beautiful operator, in such cases, at present 
existing. 

In old men the introduction of the catheter is 
occasionally a matter of considerable difficulty, owing 
to the enlargement of the third lobe of the prostate 
gland, which, from its projection into the canal, re- 
quires a modification of the instrument. In order 
to overcome this difficulty, it is necessary to elevate 



CATHETERISM. 401 

the point of the instrument more than in ordinary 
cases, as in Fig. 226. This may be accomplished 
either by bending the point slightly, previous to its 

Fig. 226. 




introduction, by passing it for an eighth of an inch 
into the barrel or ward of a pocket-key : or by in- 
troducing a finger into the rectum, when the catheter 
has reached the gland, and then elevating the point. 

Fig. 227. 




Or if the flexible catheter is used, withdraw the wire 
for a short distance, and then pass the instrument 
forwards towards the bladder. 

In cases of paralysis, or of a tight stricture, it is 
34* 



402 CATHETERISM. 

frequently necessary, in order to save trouble, to 
retain the catheter in the bladder for several hours. 
In such patients, after having evacuated the urine, 
place a little plug or cork in the extremity of the 
instrument, in order to prevent the constant flow of 
water, and fasten the catheter either by attaching it 
with tape to a suspensory bandage, as represented 
in Fig. 227, or tie the tapes firmly around the 
end of the instrument; surround the body of the 
penis with a few turns of narrow bandage ; and then 
either sew the tapes to it, or confine them by circular 
turns of another piece of tape, as represented in 

Fig. 228. 




Fig. 228, taking care not to draw them too tight. 
As the penis is, however, liable to changes of size, 
the plan first recommended (Fig. 227) is, I think, 
preferable to this, or most of the others that have 
been proposed. 

A NEW MODE OF RELIEVING RETENTION OF URINE 
WITHOUT CATHETERISM. 

As it occasionally happens that the physician un- 



CATHETERISM. 403 

accustomed to the manipulation of the catheter will 
fail in his attempts to introduce it, and as cases of 
strangury and retention of urine from spasmodic stric- 
ture are not uncommon, I would invite attention to 
the plan of M. Cazenave, as published in Rankin's 
Abstract, No. 10, December, 1849. 

" When called to a patient labouring under com- 
plete or incomplete retention of urine, I immediately 
cause the large bowel to be emptied by an oily clys- 
ter, or prescribe a purgative one, if there has been 
no motion, for fifteen or eighteen hours. When the 
first clyster has been returned I make use of another, 
less in bulk, of cold water, or (what is better), blad- 
ders filled with roughly-pounded ice, are placed 
around the penis upon the perineum, thighs, anus, 
and hypogastrium. If the patient do not pass more 
or less water, after half an hour of this treatment, I 
have him laid on the edge of the bed with a water- 
proof cloth under him, and then subject him for 
twenty or twenty-five minutes to a cold ascending 
douche, in a small continuous stream. At the end 
of this time I give another cold lavement, and con- 
tinue refrigerants, and in an hour I have generally 
been rewarded by success." 

The simplicity of these measures, and the results 
stated by M. Cazenave, together with some personal 
experience in similar measures, would certainly in- 
duce me to try it under the circumstances above re- 
ferred to. 



CATHETERISM OF THE STOMACH 



Or the introduction of a tube for the use of the sto- 
mach-pump, is performed generally without any diffi- 
culty, except that arising from the resistance of the 
patient in certain cases. Guarding, then, against 
the closing of the patient's teeth upon the fingers of 
the operator, or upon the tube, by placing a plug of 



404 



CATHETERISM, 



wood or a knife-handle between the jaws, pass the 
point of the tube directly back into the throat with 
the right hand, and with the fore-finger of the left, 

Fig. 229. 




depress its point, when it is not bent in consequence 
of the resistance of the posterior walls of the pharynx, 
as represented in Fig. 229. The course of the oeso- 
phagus renders the subsequent progress of the instru- 
ment perfectly easy. 

When it is necessary to wash out the stomach, or 
to introduce food, any of the various stomach-pumps 
that please the fancy of the operator may be used ; 
but a common injection syringe will be found to 
equal all the arrangements of the more complicated 
instruments. 

The action of the ordinary pump, and the relative 
position of both operator and patient, can be readily 



CATHETERISM. 



405 



understood by reference to Fig. 230. The plug that 
is required to prevent the closing of the teeth upon 

Fig. 230. 




the tube is not shown in this cut, as it would have 
interfered with other points of the drawing. 

In the use of the liquids to be introduced into the 
stomach, particular attention should be paid to their 
temperature, as the patient, from being deprived of 
the use of his mouth during their introduction, might 
otherwise be seriously scalded, either in the oesopha- 
gus, or stomach. Some practitioners recommend 
smearing the stomach tube with molasses, oil, or 
mucilage, previous to its introduction. To this there 
is no objection, although it is not absolutely neces- 
sary ; dipping the tube into simple cold water answers 
equally as well, and is generally more convenient. 
On withdrawing the tube from the stomach, the ope- 
rator should be careful always to place a finger on 
its open end, so as to close it tight, and thus pre- 
vent the escape of any liquid that might remain in 
the tube, into the trachea, as the tube passes the 
pharynx. 



406 CATHETERISM. 

CATHETERISM OF THE EUSTACHIAN TUBE 

Is occasionally required, in order to overcome obstruc- 
tions in the passage, which produce deafness by pre- 
venting the passage of sound along the canal. Without 
pretending to define the cases requiring this operation, 
I shall here simply refer to the operation itself, from a 
belief that many who are fully aware of its utility would 
perform it, were it not that the usually prolix directions 
of the French aurists lead them to think that the 
operation is one of difficulty. 

A slight reference to the anatomical structure of the 
part will show that there can be no very great mystery 
in the operation. The opening of the Eustachian tube 
into the pharynx being about a quarter of an inch be- 
hind the soft palate, is placed on a line with the poste- 
rior end of the inferior turbinated bone. Its orifice is 
rounded or oval ; is capable of receiving the tip of the 
little finger, and reposes against the side of the internal 
pterygoid process of the sphenoid bone. Its size, con- 
sequently, enables it to receive the point of the catheter 
prepared for this tube, with little or no difficulty. 

In introducing the catheter, place the patient's 
head firmly against the back of a chair, and having 
oiled the end of the instrument, pass it through the 
nostril of the side affected, with its point resting on 
the floor of the nose, and with its convexity upwards, 
until it reaches the posterior nares and the rounded 
edge of the soft palate, which may be readily told 
by the patient's gaging. Then turn the point of the 
instrument outwards, towards the side affected, and 
it will generally slip into the orifice of the Eustachian 
tube (Fig. 218, B). As the operation, when employed 
in deafness, requires to be frequently repeated, it is 
well to mark upon the catheter the distance from 
the front of the nose to its point when introduced 
into the orifice, in order to facilitate its subsequent 
application. The injection of air, or of liquids, will, 
of course, depend upon circumstances. 



CHAPTER VIII. 



INJECTIONS, 



Or the introduction of liquids into the various pas- 
sages of the body, are generally performed with a view 
to the relief of local derangement or to excite local 
action. They are used in the 
Lachrymal Ducts, the Ure- Fi 9- 23L 

thra, the Vagina, Rectum, &c. 

INJECTION OF THE LACHRY- 
MAL DUCTS, 
With the view of removing 
inflammation, or an obstruc- 
tion to the passage of the 
tears, is performed by means 
of a fine capillary pointed 
syringe, known as Anel's. In 
using it, hold the syringe be- 
tween the thumb and middle- 
finger, with the fore-finger on 
the piston, so as to throw in 
the fluid, and standing either 
in front or behind the patient, 
according to the eye to be 
operated on, place the point 
of the syringe in the lower 
punctum, and introduce it 
only sufficiently far to pre- 
vent the escape of the liquid. 
Then, closing the punctum of 
the upper lid, throw in the fluid by moving the piston 
with the forefinger of the hand which holds the 
syringe, Fig. 231. If the liquid passes through the 




408 INJECTIONS. 

duct to the nostril, its passage will be shown either 
by its escape from the nose in front, or behind, into 
the mouth of the patient. Simple water, or that con- 
taining a little astringent solution, is generally used 
where the object is to clear the passage and overcome 
the inflammation of the ductus ad nasum, and, when 
the syringe is properly employed, the injection of the 
puncta is a useful means of preventing the produc- 
tion of fistula lachrymalis. 

Another plan, lately proposed, of cleansing this 
duct, is by the introduction of a catheter into the 
opening of the duct in the nostril, as in A, Fig. 218. 
Though comparatively simple, it is much more diffi- 
cult than the plan just stated, and being opposed to 
the natural course of the tears and the anatomical 
structure of the part, is not generally resorted to. 

As the capillary perforation of the point of the 
syringe would render it difficult to fill it when on the 
instrument, the point should always be made moveable, 
and only applied as a nozle to the syringe, after the 
latter is filled. Sometimes, when the puncta lachryma- 
lia as well as the ducts are closed, it becomes necessary 
to dilate them previous to the use of the syringe. This 
may be done by a fine hair-like probe, also known as 
Anels's, or by the blunt end of a fine cambric needle, 
nicely rounded off and fastened in a light handle by 
its point. Slight strictures of the duct may also be 
overcome by introducing the needle into the puncta, 
and passing it as far as the sac, in the usual manner. 
On reaching this point, elevate the handle and pass 
the needle or probe in the course of the bony ductus 
ad nasum. Unless, however, the operator under- 
stands fully the anatomy of the part, he should be 
extremely cautious, lest he catch a fold of the lining 
membrane on the point of the instrument, and induce 
violent inflammation. 

INJECTION OF THE LUNGS 
Is confined, of course, to the use of air, where the 



INJECTIONS. 409 

patient, from any circumstances, is incapable of car- 
rying on his own respiration. In cases of asphyxia 
or drowning, especially the former, whether in adults 
or infants, it is often an operation of vital import- 
ance, and one which has consequently given rise to 
various plans and instruments for its performance. 
Being generally an act of great emergency, it is for- 
tunate that the operator always has the best and 
simplest means about him, in the use of his own lungs. 
In order to inflate the lungs and keep up artificial 
respiration, let the operator place the thumb and fore- 
finger of one hand closely around the patient's lips, 
and adjust his own mouth to it, whilst with the 
other hand he presses the pomum adami back against 
the vertebrae, so as to close the oesophagus, and 
prevent the passage of the air into the stomach. 
Then directing an assistant to compress the patient's 
nostril and to press upon his ribs whenever the 
lungs have been inflated by the breath of the 
operator, free the patient's mouth after each infla- 
tion; inflating and expelling the air, so as to imi- 
tate as much as possible the natural process of re- 
spiration. In cases of drowning, no time should 
be lost before commencing this operation, as it is 
generally the only chance that the individual has 
for life. 

The injecting of air, &c, into the Eustachian tube, 
may be readily accomplished by attaching a syringe 
to the catheter, when introduced into the tube, as 
directed at page 406. 

INJECTIONS INTO THE URETHRA 
Of the male are generally performed by the patients 
themselves. But as many are ignorant of the proper 
mode of performing them, and bring on inflammation 
by bruising the sides of the urethra upon the syringe, 
it is better for the practitioner to give them special 
35 



410 INJECTIONS. 

directions in regard to the manner of employing them, 
or perform the operation himself once or twice, until 
the patient has learned the proper method of doing 

Fig. 232. 




it. In order to use these injections properly, the 
patient should be directed to fill the syringe and in- 
sert its end gently within the urethra, closing the 
orifice around its point, as in Fig. 232. Then sit- 
ting down on the edge of a chair or bed, or upon a 
ball made by rolling up a handkerchief or stocking, 
so as to press upon the perineum, throw the fluid in 
by a motion of the piston, as in the figure, and, with- 
drawing the nozle, close the urethra quickly and hold 
the injection for a few minutes; then repeat the ope- 
ration twice or three times as before. An attempt 
to urinate will evacuate the fluid without difficulty. 

Injections between the prepuce and glans penis 
are often required in cases of phymosis. The only 
caution necessary to be given in these cases, is to 
prevent the patient from introducing the syringe into 
the orifice of the urethra, instead of beneath the 
prepuce. 



INJECTIONS. 411 

INJECTIONS INTO THE VAGINA, 
Like those into the urethra of the male, are not often 
required to be performed by the practitioner ; yet, 
owing to the ignorance of the patient, much of the 
benefit likely to result from their proper performance 
is lost. In the use of the ordinary female syringe, 
the patient should always be directed to lie down on 
her back, with the hips raised, and to retain the liquid 
used as long as possible, by pressing a cloth against 
the vulva. But wherever it can be done, the substi- 
tution of the French clyso-pompe, or self-injecting 
apparatus, should always be insisted on : as by using 
this instrument, a much larger amount of fluid can 
be thrown into the passage, and its whole surface more 
thoroughly acted on by it. The vaginal nozle of the 
self-injecting apparatus being placed on the tube and 
the patient seated over a basin, she can herself use 
a pint or more of any fluid for a considerable length 
of time, or, if necessary, by lieing down and arrang- 
ing the instrument, have the syringe used by an as- 
sistant without exposure. In cases of leucorrhoea, 
&c, accompanied as it often is by extreme debility, 
this plan will be found highly serviceable. 

INJECTIONS INTO THE RECTUM, 
Although generally performed by the nurse, yet 
occasionally fall to the lot of the practitioner, espe- 
cially after operations in the neighbourhood of the 
part, and the comfort of the patient will be found to 
be much involved in their proper application. In 
France, these useful means of treatment are very 
frequently resorted to, whereas it is but seldom a 
patient can be persuaded to employ them in this 
country, owing, in a measure, perhaps, to prejudices, 
but also, as I have been often told, to the pain they 
cause. Now, if properly given, their use is produc- 
tive of little or no pain, even in cases of hemorrhoids. 



412 INJECTIONS. 

In order to give one without causing pain, oil the 
fore-finger of the left hand, and press its point gently 
against the sphincter ani muscle, till its contraction 
is overcome and the finger enters the gut. Then 
pass the nozle of the syringe, also well oiled, along 
the finger, as a director, till it also enters the gut, 
when, withdrawing the finger, the fluid can be thrown 
in without difficulty ; care being taken to keep the 
point of the syringe in the line of the concavity of 
the sacrum. The position of the patient, and the 
liquid employed, must depend upon circumstances : 
but generally the patient is most comfortable lieing 
on the left side, with his back to the attendant. 



CHAPTER IX. 

EXTRACTION OF FOREIGN BODIES, &c. 

Under this head, I propose to place a class of 
minor operations, which require very little division 
of tissue, yet involve the performance of duties which 
to be successful must be learned rather from prac- 
tice and common sense than from detailed directions. 
I shall here, therefore, as in other points, be very 
brief in the details. In some of these operations, I 
also know that I trench upon the specific duties of 
those without the bounds of the profession; but as 
the practitioner may often supply their places, with 
great advantage to the public, it is deemed best not 
to pass them by. 

EXTRACTION OF TEETH. 

The operations upon the teeth being very gene- 
rally performed by a particular class of persons, the 
physician is seldom consulted in regard to them, 
except when connected with other affections. Were 
it not then for these cases, and for the fact that in 
country practice the medical man is often the only 
one who can render assistance, I should omit them 
entirely: as beneath the position which a practi- 
tioner should hold in the estimation of the public. 
I shall, therefore, confine myself to Extraction. 

The Extraction of teeth may be performed either 
with the Forceps or with the Key: the former being 
generally the preferable instrument. The instru- 
ments, as employed by dentists, are varied in num- 
ber and shape, but for ordinary use the straight, 
curved, and hawk-bill forceps, are all that are neces- 
35* 



414 



EXTRACTION OF 



sary. As certain teeth require some little modifica- 
tions of the general plan of operating, I shall treat 
of each respectively. 

In extracting the Incisors and Qanine Teeth of 
the Upper Jaw, the operator should grasp the straight 

Fig. 233. 




forceps firmly, and seize the tooth just at its junc- 
tion with the gums, taking care not to compress it 
with such force as to crush the crown of the tooth 
in the instrument. Then giving it a slight twist, so 
as to loosen the tooth in the alveolar process, pull it 
perpendicularly downwards and slightly backwards, 
in the direction of the alveolar cavity. 

In extracting the Bicuspid and Molar Teeth of 
the Upper Jaw, use the hawk-bill forceps, or those 
especially made for the molar Teeth, and moving the 
tooth from side to side, pull perpendicularly down- 
wards (Fig. 234). 

The extraction of these teeth in the Lower Jaw is 



FOREIGN BODIES. 



415 



similar to those in the upper, except in the different 
direction required for their extraction, which common 
sense will render sufficiently apparent. 

Many operators lance the gums previous to the 
application of the instrument to the tooth, especially 

Fig. 234. 




Fig. 235. 



in the molars and bicuspides ; others, again, deny 
the necessity of it, except when the key is employed. 
It may, I think, safely be left to the judgment of 
the operator. 

In extracting the Molars and Bicuspides, with the 
Key of Gf-arangeot, or its modifications, wrap the 
fulcrum with some soft substance, in order to protect 
the soft parts from pressure. Then place the fulcrum 
on the inside of the jaw, so that the claw may em- 
brace the tooth, just at its junction 
with the alveolar process (Fig. 235), 
and rotating quickly the handle of 
the instrument, draw the tooth from 
the socket. Should it not be freed 
entirely by these means, it must 
be seized by the forceps, and ex- 
tracted as before mentioned. 

For those who by practice have 
acquired the command of this in- 
strument, it will be found to answer 
exceedingly well for the extraction 
of these teeth, or of stumps. Care, 
however, is required, lest the claw be placed upon 
the edge of the alveolar process, and the bone be 
thus fractured, as is occasionally done. If, through 




416 EXTRACTION OF 

inattention, or owing to the seat of decay in the 
tooth, the fulcrum is not placed on the inside of the 
jaw, crushing of the alveolar process is very apt to 
follow, and special attention should be given to the 
action of the fulcrum, in such cases, in order to 
avoid it. 

The extraction of Stumps, when not accomplished 
by the Key, requires the use of the Elevator, the 
point of which should be firmly thrust doivn be- 
tween the stump and the socket. Then using the 
finger, a sound tooth, or the edge of the alveolar 
process, as a fulcrum, pry out the roots. But as 
the point of the elevator is exceedingly liable to slip 
and wound the cheek, the point of another finger, 
wrapped with cloth, should always be placed between 
the stump and cheek. 

The excessive hemorrhage which sometimes fol- 
lows the extraction of teeth, not unfrequently causes 
considerable trouble, although generally it may be 
arrested like that following leeching, by the use of 
nitrate of silver, or by a compress forced into the 
cavity, unless indeed it should arise from constitutional 
causes. A prescription recommended by Dr. God- 
clard, in his work on the teeth, is the following : — 
" Cause some alcohol to dissolve as much of the fol- 
lowing substances as it is capable of doing, so that 
it may be a saturated tincture ; namely, Secale Cor- 
nutum, and Gallic acid ; then add about one-fourth 
of Creosote, by measure. This tincture may be ap- 
plied by holding it to the part, or may be used to 
saturate the lint used in plugging the cavity, should 
that measure become necessary. Ergot, in the form 
of a watery solution, may, also, be used with success 
in many cases, as a gargle or mouth wash ; especially 
when the hemorrhage comes from the gums." 

Those practitoners who may be compelled to oper- 
ate upon the teeth, will find much valuable, scien- 
tific, and practical information, in the work referred to. 



FOREIGN BODIES. 417 



EXTRACTION OF CILICE. 

In Trichiasis, or turning in of the eye-lashes, or in 
a supernumerary growth of the individual cilise, the 
the constant rubbing of the hairs against the delicate 
surface of the eye-ball, produces congestion of its 
vessels, and more or less serious inflammation ; often 
indeed to such an extent as to impair the transpa- 
rency of the cornea. Under these circumstances, 
the lids should be slightly everted, and their edges 
examined, so as to detect the seat of irritation, when 
the cilise may be pulled out by a pair of forceps, 
accurately adjusted at the points of the blades. But 
in obstinate cases, the most careful extraction 
of the lashes will not remedy the disease, because 
as long as the follicle remains in the lid the hair 
may be reproduced. Having then carefully removed 
the hair, the bulb or follicle should be thoroughly 
cauterized, by passing a piecee of nitrate of silver 
along the edge of the lid, or into the opening left by 
the extraction of the eye-lash. 

EXTRACTION OF FOREIGN BODIES FROM THE EYE- 
BALL. 

Blacksmiths, and other workers in metals, not 
unfrequently suffer from sharp particles of foreign 
matter being driven into the eye-ball, so as to become 
firmly imbedded in its outer coats ; thus producing 
a most painful affection. These little particles are 
also often so fine and brittle, as to render it im- 
possible to extract them by forceps, and all such 
attempts not only fail, but render the matter infinitely 
worse, by breaking the piece. It will, therefore, 
frequently be found to be a better plan, to take a 
fine cataract needle, with a slight curve, and opening 
the lids widely, place the convex surface of the needle 
flat against the ball of the eye, and glide it gently 



418 EXTRACTION OF 

over its surface. On reaching the piece the needle will 
generally draw it out, and cause it to fall upon the lid, 
or into the hand of the operator. But if this fail, 
the touch will indicate precisely the point of the 
particle, if it projects at all beyond the surface, and 
its extraction may then be eventually effected by 
repassing the edge of the needle against the foreign 
substance, and moving it downwards or upwards, ac- 
cording to the angle at which it projects, so as to 
shave or chip it out ; an expression which I presume 
will not be misunderstood. 

EXTRACTION OF FOREIGN MATTER FROM THE 
EYE-LIDS. 

From the constant use of locomotives as aids to rapid 
travelling, the introduction of sparks and particles of 
sand between the lids and the ball has become a 
common occurrence, and one frequently productive 
of considerable trouble ; so much so, that the ap- 
pointment of an eye-cleanser to such public convey- 
ances would be a desideratum. When all simpler 
means have failed, and application is made to the 
surgeon, he should seize the edge of the lid with 
the fingers of one hand, and pressing the point of a 
pencil, or other round instrument, against its out- 
side, evert the lid, so as to turn it completely inside 
out. Then, when its inner surface is thus exposed, 
wipe away the offending matter with a camel's hair 
pencil, a fine rag, or a piece of moistened soft 
sponge. 

EXTRACTION OF FOREIGN BODIES FROM THE 
NOSTRIL. 

Coffee grains, pebbles, ribbon, &c, are occasion- 
ally introduced and become fastened in the nostrils 
of children ; thus giving rise to violent inflammation 
and suffering, and causing considerable difficulty in 



FOREIGN BODIES. 419 

their removal. With a proper knowledge, however, 
of the structure of the part, a scoop, or the curette 
of Leroy d'Etiolles, or polypus forceps, will gene- 
rally suffice to accomplish the desired end. But if 
these fail, resort may be had to sternutatories, or to 
washing out the nostril with a syringe, and to the 
use of such means as will combat the inflammation. 

EXTRACTION OF FOREIGN BODIES FROM THE EAR 

Is to be accomplished by somewhat similar means, 
although the operation here is by no means an easy 
one. When sufficient space exists between the sides 
of the external meatus and the foreign substance to 
permit the use of a syringe, a full stream of tepid 
water, thrown in whilst the ear is drawn upwards 
and backwards, will generally be found to answer 
for its removal ; or even when the body fully fills up 
the meatus, a full stream forced against it will even- 
tually wash it out by accumulating the liquid between 
it and the membrana tympani. In the use of the 
forceps, care must be taken not to force the substance 
further in. In case of insects, as earwigs, &c, 
which occasionally get in as far as the membrana 
tympani, and cause excruciating pain, the free use 
of warm olive or almond oil, by closing their pores, 
will generally produce their death, or cause them to 
seek the open air at the orifice: when subsequent 
syringing with tepid water will remove them. The 
use of landanum, and other stimulating articles, 
should be avoided, as they increase, instead of 
relieving the distress. 

EXTRACTION OF FOREIGN BODIES FROM THE 
THROAT 

Is an operation which frequently affords the practi- 
tioner but little time to make his arrangements. It 
is desirable, therefore, that the instruments required 



420 EXTRACTION OF 

should be made of such materials as can be readily ob- 
tained. Probangs, or rods of whalebone with a piece 
of sponge tied fast to one end ; the handle of a riding- 
whip, the fingers of the operator, &c, are those there- 
fore most frequently recommended. As the nature of 
the object swallowed may not, however, be such as 
to cause instant suffocation, but may, on the contrary, 
allow sufficient time to elapse for the development of 
inflammation, I would briefly allude to the rationale 
of the spasm and irritation, usually produced by 
bodies lodged in the pharynx. 

In the North American Medical and Surgical 
Journal, for October, 1828, will be found an excel- 
lent article on this subject, by Dr. Henry Bond, of 
Philadelphia, from which I mainly condense these 
remarks. Dr. Bond states that foreign bodies are 
most frequently arrested so high in the fauces or 
pharynx that they may be seen, simply by depress- 
the tongue, and that in such cases, the finger or 
dressing forceps will suffice for its removal ; whilst 
it is at this point they induce spasmodic action of 
the muscles of the glottis, by which the matter be- 
comes impacted between the bones of the os hyoides 
and the top of the thyroid cartilage. This spasmodic 
closure of the glottis, produced by the irritation of 
the foreign body, induces spasmodic efforts of 
coughing, in order to throw it off. But the pressure 
upon the epiglottis preventing the inspiration neces- 
sary for coughing, suffocation ensues, unless the 
article is quickly removed. Now, in such cases, 
Dr. Bond recommends that the patient's head be 
held erect, and in such a manner as to make the 
chin project as little as possible beyond the pomum 
adami, so as to render the introduction of the finger 
more easy, and thus release the article from its 
position, so that it may readily be ejected. But 
where the objects are smaller, or where they descend 



FOREIGN BODIES. 421 

further and pass the larynx, though the risk of suf- 
focation is diminished, the difficulties of extraction 
are increased. For such cases, resort must be had 
to forceps, of which nothing can be better than the 
oesophagus forceps of Dr. Bond, which are now 
generally kept by the cutlers, and which every prac- 
titioner should possess. These forceps are twelve 
and a-half inches long, and curved to suit the shape 
of the throat, so that they will reach as far as the 
top of the sternum — a point, beyond which little 
difficulty is usually felt from foreign bodies. 

The blades being bevelled off so as to avoid 
pinching the coats of the oesophagus, and serrated, 
are capable of seizing even small bodies, as a pin 
or fish-bone, without risk of injuring the passage. 
When coins, pieces of glass, or similar articles, are 
in question, the use of the forceps is decidedly the 
best way of removing them ; but when these are not 
at hand, a piece of common wire, bent round and 
formed into a loop, with the free ends firmly twisted 
together, and the loop then bent into a hook, may 
supply their place, or in some instances supplant 
them. Dr. Bond makes several other excellent 
suggestions, but I must refer those desirous of 
learning them to the original article, as quoted. 

THE EXTRACTION OF FOREIGN BODIES FROM THE 
TRACHEA, 

When not affected by coughing, cannot be readily 
accomplished by mechanical means, without making 
an incision into the anterior parietes of the tube ; 
but sudden blows with the hand upon the cervical 
vertebrae, the use of sternutatories, or the efforts to 
cough induced by irritating the larynx with a feather, 
will occasionally suffice. Should the substance, how- 
ever, so obstruct the passage as to threaten death, 
36 



422 EXTRACTION OF 

an incision one inch and a-half long, directly on the 
median line of the trachea should be made, so as to 
divide the integuments ; the blood be thoroughly- 
sponged off, and then two or three of the rings 
divided. The entrance of air through the opening 
will generally drive out the foreign substance. But, 
if it does not, a probe or director should be intro- 
duced through the wound, and the body pushed 
upwards. 

Tracheotomy is, however, an operation of consid- 
erable danger, and I only call attention to it as 
thus performed in cases where, without it, certain 
death would ensue ; it being, I think, a good rule to 
give every man a chance for his life, or to let him 
die of his doctor rather than from his disease ; pro- 
vided the latter point is certain. 

THE EXTRACTION OF FOREIGN MATTER FROM 
WOUNDS 

Requires the use of forceps which are modified ac- 
cording to circumstances, and generally treated of 
in the works on Gun-shot Injuries. But when the 
substance is only particles of dirt, or such fine matter 
as cannot well be seized by the forceps, the free use 
of a stream of tepid water, either by means of a 
syringe or from a sponge, will suffice. 

THE EXTRACTION OF FOREIGN BODIES FROM THE 
RECTUM 

May be accomplished by the use of a scoop or spoon 
handle, especially when employed with a speculum, 
and when the body is seated near the verge of the 
anus. But in the case of such substances as by their 
sharp projecting points would be likely to become 
imbeded in the side of the gut, the means employed 
by Marchetti in extracting the tail of a pig with stiff 
bristles from the rectum of a courtesan (as reported 



FOREIGN BODIES. 423 

in Gibson's surgery), maybe resorted to. This con- 
sists in the introduction into the rectum of a hollow 
reed, the end of the tail being passed through the 
reed so as to incase it: thus protecting the gut from 
the action of the sharp projecting points. 

The recollection of this simple plan will, I think, 
enable any one to apply the principle to numerous 
other instances, both in the rectum and elsewhere. 
When glass pessaries, &c, become broken in the 
vagina, some such contrivance, which common inge- 
nuity will readily suggest, would prove highly useful 
for its removal, without injuring the sides of the canal. 
For the removal of hardened faeces or ascarides, &c, 
either in adults or children, a salt or mustard-spoon, 
or the handle of a tea-spoon will be found to answer 
perfectly well. 

THE EXTRACTION OF FOREIGN BODIES FROM 
THE URETHRA 

Embraces so much that is connected with the treat- 
ment of Calculus, that I must refer to the works upon 
Stone and Gravel, for the consideration of the means 
required. 

EXTRACTION OF CORNS. 

Corns are a thickening of the Epidermis in conse- 
quence of pressure, and resemble a nail in shape ; 
cause pain by pressure of the point on subjacent 
parts, and are generally treated by the public at large 
by filing, scraping, or cutting off the upper layer: 
which, by preventing the boot from pressing the cen- 
tral hardening upon the sensitive cutis vera, relieves 
the pain. 

In the same way, the various corn plasters, &c, em- 
ployed for their relief sometimes prove serviceable ; 
that is, either by softening the induration and favour- 
ing its exfoliation, or by removing pressure. 



424 EXTRACTION OF 

Now, without pretending to interfere with the busi- 
ness of certain Chiropodists, I would state two plans 
of treatment which the practitioner can employ with 
marked benefit. First, the corn plasters of Sir 
Astley Cooper. These consist of pieces of buckskin 
of the size of a ten-cent piece, spread with adhesive 
plaster, and having an opening in the centre of the size 
of the corn. This plaster being warmed, should be 
so placed that the corn will project through the open- 
ing, and if one piece is not thick enough to rise above 
the top of the corn, one or two more must be placed 
on top of it, until the corn being relieved from pres- 
sure ceases to act upon the true skin : thus removing 
the pain. The application of the pressure of the boot 
upon the circumference of the plaster, tends also 
rapidly to remove the corn, by forcing its central 
portion out through the opening. 

But should more permanent relief be desired, the 
corn may be entirely removed by the following plan : 
Soak the foot thoroughly in warm water for an hour. 
Then with a small round-bellied scalpel, cut through 
the first layers of the hardened skin just on the edge 
of the healthy tissue. Seize the edge thus loosened 
with a pair of dissecting forceps and continue to dis- 
sect round the corn, on the edge of the healthy skin, 
but not cutting into it, till the pink cutis vera is 
reached, at the bottom of the little cavity thus made. 
Then, to ensure the entire destruction of the spot, 
tcuch the bottom with nitrate of silver, and thus pre- 
vent the re-appearance of the disease at this point. 
But if tight shoes continue to press upon the skin, 
new corns will inevitably be created. In this little 
operation no blood should be drawn, and relief will 
be afforded for a long period. 

EXTRACTION OF BUNNIONS. 
When the anterior portion of the metatarsal bone 



BUNNIONS AND CORNS. 425 

of the big toe is subject to long-continued pressure, 
a bursal formation is induced, which, by its increase, 
creates severe and painful inflammation or even ab- 
scesses in the surrounding soft parts (Fig. 236). 

Fig. 236. 




These, like corns, may be cured, simply by removal 
of pressure. The use of Cooper's plaster, cut to fit 
the increased size of the tumour, will therefore prove 
serviceable. But when they produce more serious 
effects than mere pain, the only plan will be to excise 
the- cyst by careful dissection and cauterization, 
guarding of course against any injury to the subja- 
cent joint. 

As connected with these parts, I must now refer 
to a small sore which is often productive of serious 
pain and inconvenience ; has engaged the attention 
of surgeons for a long period, and called forth many 
proposed plans of cure. I refer to 



Or that state of things which is induced by what is 
improperly termed the Inverted Toe Nail. This, as 
seated in the Big Toe, is usually the consequence of 
the pressure of the boot upon the inside of the toe, 
in consequence of which the skin on the opposite edge 
of the nail becomes bruised and inflamed. Or it may 
36* 



426 TOE-NAIL ULCER. 

arise from the integuments being forced up over the 
nail, thus inducing inflammation, ulceration and the 
fungus represented in Fig. 237. 

Various means have been proposed for the relief 
of this truly painful affection, in nearly all of which 
the nail has been treated as the "fons et origo" of 
the disease, and excision, eversion, cauterization, and 

Fig. 237. 




numerous other equally agreeable means are highly 
lauded : all of which if effectual (and this seems doubt- 
ful) create a degree of pain which whilst it lasts is 
not surpassed by any other operation in surgery. 
Now all this, except in the worst cases, maybe avoided 
by the following plan which I believe is due to Dr. 
Charles D. Meigs, of the Jefferson College of Phila- 
delphia, and which I have several times found effica- 
cious. 

Scrape the nail or soften it in warm water so as 
to render it moderately flexible, and then introduce 
under its angle on the sore side, some soft lint or 
charpie, so as to fill entirely the space beneath its 
edge. Next apply a very small compress upon the 
granulations or tumefied or projecting integuments, 
in order to force them off the edge of the nail, and 
confine it there by a few turns of a little strip of ad- 
hesive plaster. The continued pressure of the com- 
press, the action of the lint and the use of a loose 



OPERATION FOR TONGUE-TIE. 427 

shoe, will suffice for mild cases. But in more severe 
instances, the reduction of the surrounding inflam- 
mation, the removal of the granulations by nitrate 
of silver or excision, should precede the other means. 

There are yet several operations likely to invite 
the daily attention of the young practitioner, but 
which cannot be classed under any particular head : 
To these I would now invite attention. 

OPERATION FOR TONGUE-TIE. 

It not unfrequently happens, that parents who are 
over-anxious about the plumpness of infants, or espe- 
cially desirous that they should be able to talk at an 
early period, most earnestly request a physician to 
examine the child's mouth, in order to ascertain "if 
the baby is not tongue tied." Now, if the child can- 
not elevate the front of the tongue, or protrude it 
beyond the lips, and sucks with a peculiar smack, it 
is highly probable that the natural freedom of the 
tongue does not exist, and though it is not a matter 
of serious consequence, yet attention to it will add 
to the comfort of all concerned. 

Two defects of the frenum linguae are usually found 
in such cases, one in which the frsenum is naturally 
defective, and nearly bey ond remedial measures during 
the year; the other in which the deficiency of motion 
is owing to the existence of a thin white membranous 
piece attached to the tongue in advance of the true 
frsenum. This membrane is the most common CLUse 
of tongue-tie, and may be readily and safely removed 
as follows : Let the physician seat himself before a 
strong light, and place the child's head between his 
knees. Then let the nurse, sitting with her knees 
close to those of the physician, hold the child upon her 
lap, retaining a hold upon its hands with one of her 
hands, and depressing its lower lip with the other. 



428 LANCING THE GUMS —PROLAPSUS ANI. 

The practitioner now introducing the first and 
second fingers of the left hand beneath the point of 
the tongue, so as to place the fraenum between them, 
can, with a gum or thumb lancet, easily nick the ante- 
rior edge of the membranous fraenum, and by elevating 
the tongue cause it to yield to the pressure of his 
fingers. This little operation usually causes only a 
drop or two of blood, unless by ignorance or care- 
lessness the sub-lingual vessels should be opened. 
After this, the child will be able to suck with perfect 
freedom. 

LANCING THE GUMS. 

This extremely simple operation, though of daily 
occurrence, has not unfrequently proved quite a source 
of agitation to the young operator. It may readily 
be performed by placing the child in the position just 
described, and then with a gum lancet or sharp pen- 
knife, cutting through the gum, down to the tooth, in 
the direction of the width of the latter. The inci- 
sors will therefore require to be lanced directly in 
the middle of the gum, but the molars will demand 
a crucial incision, in order to free the entire crown 
of the tooth. Lancing' should not, however, be prac- 
tised until the gum is sufficiently swelled to prove 
painful, and the position of the tooth be thus plainly 
indicated ; but when it is done, it should be done freely, 
that is, until the tooth is distinctly felt with the point 
of the lancet. 

PROLAPSUS ANI. 

The protrusion of the Rectum as a consequence of 
Dysentery, Diarrhoea, &c, is generally relieved by 
the manual efforts of the attendant. But it occa- 
sionally happens, that owing to congestion of the 
vessel from long-continued protrusion, or extreme 
relaxation of the sphincter ani, the aid of the phy- 



REDUCTION OF HERNIA. 429 

sician will be demanded. Under such circumstances, 
it will be found highly advantageous to wash the 
part with cold water, or if there is congestion or in- 
flammation, to foment it for twenty minutes with cold 
cloths, previous to attempting the reduction. After 
which, let the practitioner oil the first finger, or the 
first two fingers of each hand, and pressing directly 
on the centre of the tumour, endeavour by gentle 
manipulation to push the folds of the bowel one after 
another within the sphincter ani ; after which, if the 
muscle contracts, nothing more is requisite. But if it 
has not sufficient power to retain the replaced parts, 
an advantage will be gained by the use of a compress 
applied to the anus, and retained by a T bandage. 

REDUCTION OF HERNLE. 

Taxis, or the reducing of hernial protrusions by the 
pressure of the fingers, is very often so simple an 
operation, that patients are able to accomplish it 
themselves ; but it also occasionally happens that it 
becomes a most important affair, the life of the patient 
depending on its early performance. In cases of 
genuine strangulation, in which there is usually the 
greatest difficulty in performing the reduction, there 
is usually such great necessity for surgical skill, that 
the general practitioner will do well to consult a sur- 
geon at the earliest moment. But in the simpler 
cases, he may make the taxis successfully, by placing 
the patient upon his back, with the thighs drawn 
up and the shoulders elevated, kneading the tumour 
by his fingers with great gentleness in the direction 
of that canal through which the bowel has protruded ; 
after which, a well-fitting truss should be employed to 
retain it in the abdomen. The importance of having 
this truss well adjusted is a matter of some moment, 
and its application should, I think, be confined mainly 
to the operating surgeon. The practitioner will, 
therefore, as a general rule, do better by turning 



430 CLUB FOOT. 

the case over to one of greater operative skill than 
he, from his limited opportunities, will usually pos- 
sess. 

CLUB FOOT. 

The prevalence of this deformity in many sections 
of the country, and the length of time generally ne- 
cessary to accomplish a cure, has generally caused 
these cases to be much neglected by practitioners. 
Every physician should, however, endeavour to make 
himself sufficiently master of this class of complaints 
to treat them during the earlier months of infancy, 
by which means he will save time, and prepare the 
case for such measures as the surgeon may subse- 
quently be called on to pursue. The mechanical 
means being very simple, may easily be employed 
by any practitioner ; but before showing those which 
are requisite in the majority of cases, I would very 
briefly state a few anatomical points closely connected 
with the treatment, which should always be borne in 
mind by those applying the different kinds of appa- 
ratus. 

Club foot, as a congenital deformity, consists in a 
departure of the articulating surfaces of the various 
bones of the tarsus from their natural relations, in 
consequence of irregular muscular action. It must, 
therefore, be recollected, that no matter in what 
direction the foot is turned, one set of muscles are 
spasmodically contracted, and the others more or less 
weakened, or partially paralysed, by continued ex- 
tension. The articulating surfaces of the tarsal 
bones being also often considerably separated from 
each other by malposition, it follows that even 
when the foot is placed in its proper relations to 
the leg, a long period must elapse before the elon- 
gated ligaments will contract to a proper length ; 
or the articulating surfaces of the bones be modi- 
fied ; or before muscles, more or less wasted by ex- 
tension, will again be capable of resisting the con- 



CLUB FOOT. 431 

tractions of the set which produced the deformity. 
The sooner, therefore, the treatment is commenced 
after the month, the greater will be the chances of 
success. 

Out of a very considerable number of cases that 
have fallen within my observation, few have been 
cured under periods of several years. By cured, I 
mean, placed in such a condition, that when run- 
ning about for three or six months with ordinary 
shoes the feet will show no tendency to return to 
their unnatural position. "Very many cures, I am 
aware, have been reported in extremely short periods ; 
but this only shows that opinions differ widely as to 
what constitutes a cure. In my opinion, no case is 
cured unless it will stand the test of six months exer- 
cise without a boot. The rule I pursue, therefore, 
in every case, is to tell the parent that the child, 
no matter how young, will probably have to wear a 
stiff shoe of some kind, until eighteen or twenty 
years of age, or until the osseous system is fully 
developed. 

Having known many practitioners misled in this 
matter by inconsiderate statements of results, and 
wishing to prevent misapprehension on a point of 
great practical importance, I repeat the opinion that 
most patients will be liable to a return of the defor- 
mity, unless the mechanical means are long continued, 
and unless a shoe of more than ordinary stiffness is 
worn until the bones of the foot are fully developed, 
even when the foot appears to be perfectly straight 
when removed from the splints. 

The division of tendons, though a simple operation, 
has not been, in my observations, essential to a cure. 
The operation I have found to facilitate the use of 
mechanical means, in consequence of its reducing the 
amount of resistance to the action of the shoe, and 
thus saving the integuments from a degree of pres- 



432 



PES EQUINUS. 



sure that might result in excoriation or sloughing ; but 
mechanical means, carefully used, are capable of ac- 
complishing the same result without an operation. 
In the treatment of club-foot, each variety will 
usually require some modification of apparatus ; 
but, as after treating the two most common varie- 
ties, such modifications can be readily made by 
any physician, I shall limit this account to these 
forms of the complaint, rendering the details of the 
pathology, &c, as brief as possible. The simplest 
form of Club-foot is 



PES EQUINUS. 

In this variety, the heel is elevated by the contrac- 
tion of the gastrocnemius, soleus, &c, and the pa- 
tient, if allowed to walk, will rest his weight, with some 
slight modifications, mainly on the Metatarso-Pha- 

langial articulations. In 
Fig. 238. the young infant, the ends 

of the toes present perpen- 
dicularly downwards, the 
instep appears to be almost 
a direct continuation of the 
leg, and the sole of the foot is 
nearly on a line with the 
calf. In this variety, owing 
to the elevation of the heel, 
the astragalus presents pro- 
minently forwards, and the 
scaphoid and cuboid, in con- 
sequence of the elongation 
of the dorsal ligaments, also 
fall forwards ; thus giving 
to the foot a strongly- 
marked arch, the centre of 
which is about the cuneiform bones. The sole of 
the foot in the young infant is frequently quite flat, 




PES EQUINUS. 433 

but in children who have walked, and especially in 
adults, it is more or less concave, in consequence of 
the contraction of the short flexors of the foot, as 
well as of the plantar fascia. 

Bearing in mind the extreme fineness of the skin 
in young children, and its liability to inflame from 
even moderate pressure, the practitioner who is about 
to treat club foot, should commence at the earliest 
possible period after the month, by manipulating the 
foot, calf, &c, so as to favour a change of position, 
and, at the same time, instruct the mother or nurse how 
to carry out the subsequent treatment. 

In order to harden the skin, he may commence by 
soaking the foot for fifteen minutes in a decoction 
of white oak bark ; which will prove most serviceable 
if employed cold or cool. Then, after a few days, 
let him commence his manipulations by placing his 
four fingers on the instep, and his thumb beneath 
the ball of the foot, and endeavour to bend the 
foot at the ankle; making friction at the same time 
upon the calf of the leg, in order to favour relaxation 
of the contracted muscles. By a judicious perse- 
verance in such motions, considerable change can be 
effected in the parts before a child is six months 
old ; after which, strips of muslin drawn from the foot 
up to the knee, or adhesive strips made fast around 
a kid sock, and then around a bandage above the 
calf, will prove serviceable. 

As soon as the skin seems tough enough to sustain 
moderate pressure, and this of course will vary some- 
what in different children, a regular club-foot shoe 
may be resorted to. I am generally able to apply 
a light shoe between the ninth and twelfth month, 
taking care at first merely to apply it in the natural 
position of the foot, and waiting a few days until the 
child becomes accustomed to the restraint. After 
this, say about the end of the tenth month, in a large 
child, the mechanical treatment, hereafter detailed, 
37 



434 PES EQUINUS. 

may be commenced. Should there, however, have 
been any marked difficulty in the extension of the 
foot by the hand, it will facilitate the treatment to 
divide the tendo-achillis. This may be readily done 
as follows : Pick up a fold of the skin over the tendon, 
about one inch above the extremity of the os calcis, 
and introduce a sharp-pointed penknife blade into 
the fold, with its blade flat beneath the skin. Pass 
it on beneath the skin, until it is directly over the 
tendon, but do not let the point perforate the integu- 
ments on the opposite side to that where it entered. 
Next, turn the blade so that the cutting edge will 
present to the tendon, and hold it firm. Then ex- 
tending the foot, cause the tense tendon to bear 
against the blade of the knife, when the division of 
the tendon will be readily effected. Turning the 
knife again upon its side, withdraw it at the point of 
entrance ; close the little puncture immediately with 
the finger, to prevent the entrance of air, and apply 
over the wound a morcel of adhesive plaster. The 
tendon being thus divided, the limb should be left in 
its natural condition from five to seven days, during 
which time the divided edges of the tendon will reunite 
by a new matter, which being readily extensible, 
will favour the elongation of the contracted muscle. 
After which mechanical means will effect the cure. 

Although this operation facilitates the cure by 
diminishing the resistance, and saving the skin 
from a certain amount of pressure, yet it is by no 
means always necessary. The penknife referred to 
in the operation, if stiff in the spring, will answer 
every purpose in the division of this tendon ; but if 
deemed too common an instrument, a similarly shaped 
blade, made a little longer and fastened firmly to a 
handle, may be used, and called a "Tenotome." 

Either with or without the division of the tendo- 
achillis, the following mechanical means, shown in 
Fig. 239, will be necessary to accomplish the cure. 



PES EQUTNUS. 



435 



This apparatus being a slight modification of the 
shoe of Scarpa, may be readily obtained of the 
cutlers, and is designated as an "Adjusting Shoe." 




The sole is made of sheet iron, and has four holes or 
fenestra in the heel, as seen at A, these fenestra being 
intended for the passage of the tapes of the gaiter B. 
The remaining portion of the cut explains itself. 

In using this apparatus, after having it made to 
fit the limb of the child, and after having pursued 
the preliminary treatment until the tenth or twelfth 
month, the practitioner should proceed as follows : 
Apply a gaiter, made of the softest buckskin, 
directly at the ankle without the intervention of 
wadding, and lace it moderately tight. Next, 



436 



PES EQUINUS. 



Fig. 240. 



apply the splints upon the back part of the limb ; 
place the foot in the shoe (applying a piece of kid, 
&c, to the inside of the sole of the shoe to pre- 
vent chafing), and then drawing the tapes of the 
gaiter through the holes shown at A, tie them be- 
neath the sole, so as to bring the heel of the foot 
directly in contact with the heel of the shoe. Then 
lacing up the shoe, buckle the strap around the leg, 
and also that about the thigh, and see that the angle 
of the shoe and leg correspond with the natural 
position of the foot. The shoe, thus applied, should 
be worn for an hour in the morning, and again applied 
for an hour in the afternoon, until the limb becomes 
accustomed to it, and the child will bear a slight 
flexion of the foot. To effect this, turn the screw 
on the side of the instrument a little, from day 
to day, so as to elevate the toes and bring down 
the heel, and thus gradually 
elongate the contracted muscle. 
To bring the foot to its 
proper position, that is, so that 
the child can place the sole flat 
upon the ground, will generally 
occupy from three to six weeks, 
after which, the adjusting shoe 
may be removed from the 
splints, and an ordinary leather 
shoe substituted. But it is per- 
haps better, in order to prevent 
chafing at the knee and ankle- 
joints in walking, to substi- 
tute an apparatus like that in 
Fig. 240. 

This, to ensure a cure, should 
be worn by the patient for 
several years after he is able to 
run about, in order to give time for the remodelling of 
the bones and ligaments, as the little patient grows. 




VARUS. 



437 



In thus defining the periods required for the dif- 
ferent steps of the treatment, nothing more than an 
average'can be offered. My experience has, however, 
convinced me, that the time usually assigned for the 
treatment of club foot, and especially for a radical 
cure, is too short, unless no account is taken by the 
surgeon of the measures pursued by the parents after 
the earlier periods of his treatment. A practi- 
tioner may understand, that when a case of club foot 
is placed in such a condition that the patient can 
walk about with the apparatus on, without showing 
any great deformity, it may be called a cure; but the 
parent who finds the feet disposed to return to their 
original deformed state, as soon as they are removed 
from the shoes, and who is compelled to furnish such 
shoes and splints for a dozen or more years, will 
have a different idea of the case. The physician will, 
therefore, act wisely, who explains these circum- 
stances to the parent before commencing the treat- 
ment. 

VARUS. 

In Varus, or that form of club foot in which the foot 
is bent inwards, a more 
complicated deformity is -%• 241. 

found than that which 
exists in Pes Equinus. 
In this variety, the meta- 
tarsal bones are bent in- 
wards at varying angles 
with those of the last 
row of the tarsus. The 
tarsal bones, especially 
the cuboid, are also 
more or less twisted 

upon the calcis, and that bone, in addition to 
the elevation of its posterior extremity, is also often 
rotated inwards. The sole of the foot, therefore, 
looks obliquely upwards and inwards, whilst, at the 
37* 




438 



VARUS. 



Fig. 242. 



same time, the distance between the heel and toes is 
considerably diminished (Fig. 241.) 

Should the child have walked, the cuboid bone will 
show signs of having sustained the greater portion 
of the weight, and there will usually be a callous lump 
on the integuments, as the result of this pressure. 

Of the particular changes in the dorsal and plantar 
ligaments, and in the muscles and tendons, I can 
here say little, as the description would extend my 
remarks beyond what seems necessary for a treatise 
like the present. Those who may wish details, will find 
them in most of the modern works on surgery. 

Varus, or rather varus combined with pes equinus, 
is the form of club foot that is most frequently seen 

in infants. It is also the 
variety that most seriously 
demands early attention on 
the part of the practitioner. 
If possible, therefore, the 
child should not be allowed 
to bear any weight on its 
foot until the deformity 
has at least been reduced 
to simple Pes Equinus. In 
the young infant, say within 
three months, this inward 
displacement may by cau- 
tion and perseverance be 
certainly overcome. The 
simplest means that I know 
of will be found in the fol- 
lowing : Apply on the out- 
side of the leg a straight 
splint, similar to that seen in Fig. 242, and pass around 
the metatarso-phalangial joints a few turns of band- 
age, ribbon, or similar article, carrying each turn 
around the lower end of the splint, or through its 
fenestrum, as seen in the figure. By tightening 




BANDY LEGS, OR BENT BONES. 439 

this band from day to day, and by such manipulation 
as has been described under the head of Pes Equi- 
nus (except that the endeavour should here be, simply 
to bring the toes into the line of the foot, and not to 
meddle with the heel until the case is converted into 
Pes Equinus), success will be readily obtained; sim- 
ple straightening of the toes being alone attempted. 
When the outside of the toes can be made to touch 
the splint and remain there without the use of much 
force, the case should be treated precisely as if it 
had originally been of the first variety that I have 
mentioned, that is, of Pes Equinus. Occasionally, the 
division of a tense tendon, or of a very tense band of 
fascia, may facilitate the cure ; but, not unfrequently, 
if the child is attended to within the period mentioned, 
the maneuvres just detailed will prove sufficient. 

BANDY LEGS, OR BENT BONES. 

This unsightly condition of the bones of the leg 
requires but little explanation. It is most fre- 
quently the result of placing heavy children upon 
their feet, before the tibia is sufficiently ossified to 
sustain their weight. Besides the unsightly cha- 
racter of the deformity, this curving of the tibia 
is apt to interfere with very active progression, 
and as it can be remedied by simple means, provided 
they are persevered in, the case is one which should 
receive early attention. The principles of the treat- 
ment are to remove or diminish the weight sus- 
tained by the tibia, and then by gentle pressure to 
restore the pliant bone to its straight condition. 
Although nature may accomplish these results un- 
aided, any simple apparatus, acting on the principles 
just detailed, will aid materially in the cure. One 
similar to Fig. 243 is all that I have found necessary 
in most cases. It resembles the shoe in which chil- 
dren having club foot usually walk (as before detailed) ; 



440 INSERTION OF GLASS EYES. 

but in addition, it has two padded pieces or splints 
of sheet iron, as at A and B, which fasten around the 
limb, on the opposite side and on the front of the 
curvature. By moving every 
Fig. 243. week the screw attached to 

A, such a gradual pressure 
can be made at the point of 
greatest convexity, as will 
bring the bone into its proper 
line. The upper straps in 
the figure assist in support- 
ing the weight of the body, 
the greater part of it being sus- 
tained by the side steel splints 
instead of by the tibia. As the 
development of the osseous 
system is rapid at this period 
of life, a cure can generally 
be effected in a few months. 

Much of the success at- 
tendant on the treatment of 
the deformities that I have 
now referred to, will depend 
on the character of the ap- 
paratus employed. Each case 
will require its own instru- 
ments, and they must be changed in accordance with 
the growth of the patient. For the information of 
those who cannot obtain proper shoes and splints 
in their own locality, I would mention that John 
Rohrer & Son, Sixth street below Arch street, Phi- 
ladelphia, keep and manufacture a very large assort- 
ment for all kinds of deformities. 

INSERTION OF GLASS EYES. 

When, from any cause, the ball of the eye has been 
injured and vision destroyed, it is often desirable 




INSERTION OF GLASS EYES. 441 

to conceal the deformity by the use of a Glass 
Eye. This consists in a section of a sphere of 
glass accurately coloured to suit the different ap- 
pearances of the human eye, and intended to be 
placed in front of the remains of the injured ball, 
where the pressure of the eyelids retain it, and where 
the action of the stump, or remains of the eye, gives 
it motion. So perfectly is this sometimes the case, 
that unprofessional observers have not been able to 
tell a glass eye from the sound one. 

These eyes are now imported in considerable 
numbers and at moderate prices by Bauersach, Mar- 
ket Street, Philadelphia ; Milhaud, Broadway, New 
York, &c. : and as their insersion is very simple, 
it is to be hoped that the Profession will more 
frequently employ them to conceal deformities, 
which are often a constant source of mortifica- 
tion to the patient. By inserting them personally, 
they will do away with the advantages now reaped 
by charlatans, at their expense. 

Introduction. — After having selected an eye of 
the color, size of pupil, and prominence of ball, that 
is desired, seize it between the thumb and fore-finger 
of the right hand, and dip it into a glass of tepid 
water. Then elevate the upper eyelid by the thumb 
of the left hand, and sliding the glass eye under its 
edge, let the lid fall gently upon it. Next, depress 
the lower lid by the middle finger of the left hand, 
and slip the false eye within it : when the subsequent 
action of the lids will retain it in its place, and give 
the proper central position in the orbit. 

In order to remove the eye, take a bodkin, or 
short probe, and depressing the lower lid, slip its 
triangular end between the lid and the ball and 
slightly under the edge of the glass eye. Then de- 
pressing the other extremity of the probe on the 
cheek, so as to make it act as a lever, catch the eye 
with the left hand, or with a handkerchief held to 



442 EXCISION OF PTERYGIUM. 

receive it. After its removal, cleanse it in a little 
water ; dry it thoroughly and put it away in soft 
cotton in order to preserve an equal temperature, 
till it is again wanted. Want of attention to the 
changes of temperature is a frequent cause of the 
cracks so often complained of in these eyes. Being 
very brittle, the change from the warmth of the 
cavity of the orbit, to a glass of cold water, will be 
sufficient to break them. 

The movements required for the introduction and 
removal of these eyes are so simple, that patients 
readily perform them for themselves. At first the 
glass eye should only be worn three or four hours, 
lest it produce inflammation of the ball on which it 
is placed : but afterwards it may be worn for any 
length of time. 

In the selection of eyes, care should be taken to 
see that they are perfectly smooth on the edges, as 
otherwise they will irritate the ball. But I do not 
think it always necessary to use first a small eye 
and then another, during several weeks, in order 
as is said, to dilate the lids, unless we wish, as eye 
doctors do, to mistify the patient with the difficulty 
of the operation. Should the ball continue to waste 
away, then a larger eye will of course be demanded. 

EXCISION OF THE PTERYGIUM. 

When the vessels of the conjunctiva become per- 
manently enlarged, a thickening of the membrane 
and of the sub-conjunctival cellular substance results, 
which by extending over the cornea, interferes with 
vision. This diseased portion is usually of a trian- 
gular form, and commencing at the inner canthus of 
the eye, gradually diminishes in breadth, till it ter- 
minates by a sharp apex, somewhere on the edge of 
the cornea. Though generally single, we occasion- 
ally find more than one (Fig. 244), and in such cases 
their continued growth soon destroys the patient's 



CATOPTRIC EXAMINATION OF THE EYE. 443 

sight. When the prolongation of a pterygium seems 
likely to extend to the pupil, and to interfere with 
vision, it should be operated on. This may be done, 
either by seizing the enlarged conjunctiva with a 
pair of fine forceps, or with a hook. Then drawing 
it off from the sclerotic coat, cut out the central 
portion, with its vessels, by a snip of the scissors : 
cutting from the cornea towards the internal canthus 

Fig. 244. 




of the eye, and taking care not to include the plica 
semilunaris. Or if the base of the pterygium is not 
very wide, make a simple transverse incision through 
it, down to the sclerotica, at a point half-way between 
the internal canthus and the edge of the cornea, so 
as to divide entirely the vessels supplying the 
growth. Then pass a sharp-pointed stick of nitrate 
of silver in the line of the incision, and cauterize its 
edges ; so that the circulation being destroyed in the 
part, the enlarged membrane may shrivel away. 

ON THE CATOPTRIC EXAMINATION OF THE EYE 
AS A MEANS OF DIAGNOSIS IN CATARACT. 

The difficulty of distinguishing Cataract from 
Amaurosis is not unfrequently experienced even by 
the surgeon of extended experience. That the 
general practitioner should, therefore, occasionally 



444 CATOPTRIC zxamikati : 

cause a pane: 

i Catari. 
■ - - _ 

- - 
_ 

1 from Ran 
45, and from Lawrence oa 

In I Sum 

: 
amaurosis 

2 - 
_ - - - 

I 

- 

ns, and _zieat. 

? of optics- 3 

e always 

- 

_ 
! 

- 

I 

- 

[i _ - . . 

i 

■ 

- - 

_ 

_ 
- 



CATOPTRIC EXAMINATION OF THE EYE. 445 

portion of the capsule destroys the inverted image, 
but leaves the two upright, thus indicating very posi- 
tively the seat of the disease. 

Certain precautions are, however, to be observed, in 
order to secure success : — 1st. The pupil must be 
dilated to double or treble its ordinary size, and this 
may be almost instantly effected by dropping into the 
eye a solution of atropine, grs. j., water, giij., the lids 
being immediately closed, so as to prevent the escape 
of the solution with the tears which it excites. 2d. 
The eye must be examined in a dark room by means 
of a clear and steady burning lamp or candle. 3d. 
The observer should be seated in front of the patient, 
so that he may look down into the eye rather than 
up. 4th. After finding the image as formed by the 
cornea, being the usual reflection of an image seen 
upon any eye, under ordinary circumstances, the 
observer if looking in a direct but obliquely trans- 
verse line from this image, will notice the erect but 
paler image of the front of the lens, and lastly, and 
partly between the two, the small inverted image 
of the posterior face of the lens. If these images 
are not readily seen, he should move the light slowly 
from side to side, until he seizes them, and to ap- 
preciate the effects of the test in cases of disease, 
practice the experiment first upon the healthy 
eye. These precautions being taken, the three images 
will certainly be present if cataract does not exist ; 
unless it be so slightly developed as merely to 
constitute a very slight haziness, which, therefore, 
permits the transmission of light, or is situated at 
the circumference of the lens where it cannot prevent 
the reflection from its centre, the latter being 
readily detected by noticing that the images become 
faint, or disappear at this point. 

When these three images are seen, there can be 
no disease of the cornea, or anterior or posterior 
face of the lens or capsule. The absence of any one 
38 



446 EXCISION OF THE UVULA AND TONSILS. 

will, therefore, indicate the surface affected. In 
amaurosis, all three of the images are seen ; in per- 
fect cataract, only that formed on the cornea. 

EXCISION OF THE UVULA 

Is frequently rendered necessary, in consequence of 
the elongation of the extremity of its mucous mem- 
brane, which falling upon the posterior portion of the 
tongue and pharynx, or even in some instances into 
the glottis, or upon the epiglottis, keeps up a con- 
stant tickling, which induces so much coughing, and 
copious expectoration, as to similate the commence- 
ment of phthisis pulmonalis. As this elongation is 
at first merely the result of a slight oedema of the 
mucous membrane, resulting from inflammation, com- 
mon astringent gargles of oak bark, powdered galls, 
tannic acid, powdered alum, tinct. ferri chloridi, 
nitrate of silver, &c, may reduce it. But if, when 
free from inflammation, it continues permanently 
elongated, its removal by the knife becomes neces- 
sary. This may be readily effected by seizing the 
point of the uvula with a pair of dressing forceps, 
and clipping off merely the tip, with a bistoury or a 
pair of blunt-pointed scissors ; care being taken not 
to cut off so much of the point as to involve the mus- 
cle, lest, by destroying the action of the part, we 
should impair the voice. This operation causes 
little or no pain, is quickly done, and requires no 
further after-treatment than the use of a gargle of 
cold water or of some mild demulcent, as gum arabic 
or slippery elm, from time to time, with attention to 
diet. 

EXCISION OF THE TONSILS. 

In consequence of the chronic enlargement and indu- 
ration of these glands, their excision is often required, 
in order to relieve the irritation of the throat, and 
the effects upon the voice and respiration which they 



EXCISION OF THE TONSILS. 



447 



produce. Two means were formerly recommended 
for their removal, to wit, the ligature and excision; 
but one only is now generally resorted to, and I 
shall, therefore, confine my remarks to Excision. 

When all acute inflammation is removed, and the 
means of scarification, touching with tincture of iodine, 
&c, have failed, the upper portion of the gland, or 
that next to the velum pendulum palati, should be 
removed. Of the various instruments employed for 

Fig. 245. 




this purpose, the modification by Schively, of Dr. Phy- 
sick's instrument (Fig. 245), will, I think, be found 
to be the most convenient and safe. Fahnestock's 
instrument, although a good one in some respects, is 
objectionable from the difficulty attendant on sharp- 
ening a circular knife, and also from its manufacture 
having been patented. With either, however, the 
operation is simple, and performed as follows : Seat 

Fig. 246. 




the patient on a moderately low chair, and direct the 
assistant supporting the head, to place his fingers 



448 



REDUCTION OF PARAPHYMOSIS. 



beneath the angle of the patient's jaw, so as to force 
the gland into the throat, and render it more promi- 
nent in the pharynx. Then, whilst the mouth is 
widely opened, pass the instrument into the throat, 
with its flat surface parellel with the tongue, and on 
reaching the gland, turn the handle up, so as to in- 
clude the tumour in the ring of the instrument: when 
a rapid movement of the concealed knife clips off 
the portion coming within its range. This is some- 
times brought out by the withdrawal of the instru- 
ment, or is spit out by the patient (Fig. 246). 

In this operation, I would advise the young prac- 
titioner not to be too anxious about the size of the 
piece to be removed: as the excision of the project- 
ing third of the gland will generally be followed by 
the absorption of the remainder, and is all that is 
necessary. 

R EDUCTION OF PARAPHYMOSIS. 

When, in children or adults, a rather narrow pre- 
puce is forcibly retracted, it will sometimes produce 
such a constriction of the parts adjacent to the corona 
glandis as to develop severe 
inflammation, and possibly in- 
duce gangrene. 

To obviate this, as well as to 
relieve the sufferings of the 
patient, the physician should 
at once attempt to restore the 
parts to their natural condi- 
tion. 

If serum has been effused be- 
neath the mucous coat of the 
prepuce, and the parts have 
become puffy and swollen 
(Fig. 247), he should first eva- 
cuate it by numerous small and superficial punctures 
with the point of a lancet, and then, after holding the 



Fig. 247. 




REDUCTION OF PARAPHYMOSIS. 449 

penis for a few minutes in very cold water, seize the 
body of the organ behind the corona, between the first 
and second fingers of each hand. Next, whilst gently 
drawing the prepuce forward with the fingers, force 
or knead the head of the penis backwards with the 
thumbs, or if one hand has seized the constricted part, 
press back the end of the penis with the fingers of 
the other, in the same way that any one would en- 
deavour to invert the finger of a glove. 

After its reduction, simple cold bathing of the part 
is all that is requisite. 

I have now treated of most of the minor opera- 
tions of surgery, or of such as do not involve an exten- 
sive division of tissue, and are likely to fall to the 
daily lot of most practitioners : excepting, perhaps, a 
few upon the organs of generation, such as stricture, 
phymosis. As it would be difficult to refer to these 
in the brief manner that has been laid down as the 
plan of this work, without doing injustice to the sub- 
ject, or perhaps causing injury to the patient, I 
feel compelled to pass them by. 
38* 



INDEX. 



Abdomen Bandage of, 75 

Paracentesis of, 368 
Abscesses, Puncture of, 374 

Diagnosis of ; 375 

Lancets, 30 
Acids, Issues from, 353 
Acupuncturation, 361 
Adhesive Strips, 41 
Amesbury, 256, 274 
Amputations, 108, 323 
Anatomy of Veins, 328 
Anaesthetics, 315 
Angle of Jaw, Bandage of, 85 
Ante-Brachial Trough, 159 

Hyponarthecia, 175 
Anterior 8 of Chest. 89 
Anus, prolapsus of, 428 
Apparatus for Dislocations, 287 



of Dressings, 28 
T Bandage of, 114 

Application of Bandage, 64, 7 1 
Dressings, 27 

Arrest of Hemorrhage, 377 
Bladder, 391 
Leeches, 344 
Rectum, 390 

Arteriotomy, 341 

Assistants, duties of, 313 

Bandages, Circular, 65, 69 
Compressing, 66 
Dividing, 65 
Double-Headed, 63 
Expelling, 66 
Manufacture of, 62 
Recurrent, 65. 106 
Oblique, 65, 70 
Retaining, 66 
Reverses of, 72 
Simple, 61 
Single-Headed, 63 
Spica, 65 
Spiral, 65 
Starch, 82 
Uniting, 65 

Bandaging, 61 

Bandy Legs, 439 

Barton's Bandage for Jaw, 86 



Barton's Bran Dressing, 271 
Fracture of Radius, 229 
Handkerchief, 169 

BeJlingham's Compressor, 382 

Bent Bones, 439 

Bistouries, 30 

Bi-Temporal Triangle, 146 

Bladder, Hemorrhage from,39 1 

Bleeding, 328 

at Ankle, 338 

in External Jugular, 336 

in Hand, 336 

Blisters, 350 

Bloodletting, 328 

Local, 342 

Body, Invaginated Bandage of 
121 

Bond's Forceps, 420 

Bones of Fore-arm, Disl'n, 300 

Fracture, 228 

Metatarsal, Disl'd, 310 

Fractured, 280 

Tarsus, Dislocation, 309 

Fracture of, 279 

Boyer, for Fract. of Clavicle, 215 
Neck of Humerus, 223 
Shaft of Humerus, 224 
Fract. of Olecranon, 231 
Fracture of Femur, 253 
Fracture of Calcis, 279 

Bran Dressing, 271 

Breast Bandages, 92 

Buckled Bandages, 135 

Bunnions, 424 

Buttock Double T of, 117 

Calcis, Fracture of, 279 

Carpo-Dorsal Triangle, 163 

Carpo-OlecranonHand'c'f, 164 

Carpus, Dislocation of, 300 
Fractures of, 230 

Carved Splint, 226, 227 

Cataplasms, 51 

Catheterism, 398 

of Eustachian Tube, 406 
of Stomach, 403 
of Urethra, 398 

Catoptric examination, 443 

Caustic Holder, 30 

Cervico-Brachial Sling, 159 



INDEX. 



451 



Chapman's Inclined Plane, 241 

Charpie, 32 

Chest, Bandage of, 89 

T Bandage of, 115 
Chin, Sling of, 129 
Chloroform, 316 
Ciliae, Extraction of, 417 
Circular Bandage, 69 
Clavicle, Dislocation of, 293 

Fracture of, 211 
Clinical Frame, 193 
Clove-Hitch, 302 
Club Foot, 430 
Coates' Extending Band, 243 

Perineal Band, 245 
Collodion, 49 
Compound Bandages, 111 
Compresses, 36 
Compress, Cribriform, 38 
Compressing Bandage, 66 
Compressor of Bellingham, 382 
Concretions, Salivary, 374 
Condyles, 225 
Corns, Extraction of, 423 
Continued Suture, 394 
Cooper, Sir Astley, 232 
Coronoid process, Fract.of, 238 
Cotton, 35 
Court Plaster, 50 
Cravat, 152 

Critchett Adhesive Strips, 47 
Crossed Bandages, 83 

of Chest, 87, 89 

of Breast, 92 
Cupping, 347 
Cutaneous Irritation, 350 
Definition of Minor Surgery, 

311 

Demi-Gauntlet, 79 

Dessault's Apparatus for fract. 

ofClavicle,212 

for fracture of 

Olecranon, 232 

Apparatus for fracture 
of Patella, 265 

Splints, 249 
Director, 29 
Dislocations, 289 

of Lower Jaw, 291 
of Head and Trunk, 291 



DisFns of Vertebrae, 292 
of Clavicle, 293 
of Ribs, 292 
of Upper Extremity, 

295 
of Head of Humerus, 

295 
of Head of Radius, 298 
of Forearm, 297 
of Bones of Forearm, 

300 
of Wrist, 300 
of Magnum, 300 
of Metacarpal Bones, 

301 
of Phalanges. 301, 310 
of Lower Extremity, 

304 
of Hip-Joint, 304 
of Patella, 308 
of Bones of Tarsus, 309 
of Fibula, 309 
of Head of Tibia, 309 
of Metatarsal Bones, 
310 
Dividing Bandage, 66 
Dorsey's Splints, 266 
Dorso Bis- Axillaris, 154 
Double Spica Handkerchief, 

157 
Double T of Buttock, 117 

Hand, 117 
Dressings, 27 

Apparatus of, 28 
Instruments of, 28 
Pieces of, 31 
Dry Suture, 397 
Dupuytren's Splint, 278 
Duties of Assistants, 313 
Ear, T Bandage of, 113 
Eighteen-tailed Bandage, 249 
Electro-Puncture, 363 
Elevator for Fractures, 240 
Epididymitis, strips in, 48 
Ether, 316 
Eustachian Tube. Catheterism 

of, 406 
Excision of Pterygium, 442 
of Uvula, 446 
of Tonsils, 446 



452 



INDEX. 



Expelling Bandage, 66 
Extending Bands, 243 
Extraction of For'n Bodies, 413 
of Ciliae, 417 
of Foreign Bodies from 
Eyeball, 417 
Eyelids 418 
from Ear, 419 
from Nostril, 418 
from Throat, 419 
from Rectum, 422 
from Urethra, 423 
of Bunnions, 424 
of Corns, 423 
of Teeth, 413 
of Foreign Matter from 
Trachea, 421 
Eye, Crossed Bandage of, 83 
Facial Triangle, 147 
Fahnestock, Reduc. of Dis., 304 
Femur, Fractures of, 241 

Dislocation of, 305 
Fibula, Dislocation of, 309 

Fracture of, 278 
Figure of 8 Bandages, 83 

of Neck and Axilla,91 
Elbow, 98 
Wrist, 99 
both Thighs, 100 
Knee, 100 
Instep, 100 
Ankle, 100 
Finger, Spiral of, 77 
Flexor of Wrist, 162 
Foramen Thyroideum, Dislo- 
cation into, 308 
Forceps, dressing, 28 

simple, 29 
Forearm, Dislocation of, 297 

Fracture of, 228 
Foreign Bodies in Eye call, 
Extraction of, 417 
from Ear, 419 
from Nostrils, 418 
from Throat, 419 
Dr. H. Bond's For- 
ceps for, 420 
from Trachea, 421 
Foreign Bodies in Rectum, 422 
in Urethra, 423 



Foreign Matter in Eyelids,418 
in Wounds, 422 
Formation of Issue, by Potash, 

Acids, &c, 353 
Four-Tailed Bandage of Head, 
128 
of Neck, 129 
Chin, 129 
Face, 130 
Breast, 131 
Fox's Bandage for Clavicle, 217 
Fracture-Box, 269 
Fractures, 201 

of Nose. 208 
Skull,' 208 
Lower Jaw, 209 
Vertebrae, 210 
Sternum, 211 
Pelvis, 211 
Ribs, 211 
Clavicle, 211 
Scapula, 221 
Neck of Humerus, 

223 
Upper Extremity, 223 
Humerus, 224 
Condyles, 225 
Forearm, 228 
Lower end of Radius, 

229 
Metacarpal Bones, 

230 
Olecranon, 231 
Phalanges, 231 
Coronoid process, 235 
Shaft, 235 
Ulna, 235 

Lower Extremity, 237 
Femur, 241 
Patella, 265 
Leg, 269 
Fibula, 278 
Os Calcis, 279 
Bridges, 280 
French Spiral, 81 
Fronto-Dorsal, 149 
Fronto-Occipilal Triangle, 144 

Occipito-Labialis, 146 
Gaiter-Laced, 136 

Physicks, 244 



INDEX, 



453 



Galen, Bandage of, 127 
Gauntlet. 78 

'Demi, 79 
Gerdy's Bandage for Olecra- 
non, 235 
for Patella, 267 
Gibson's Bandage for Jaw, 209 
Hagedorn, 260 
Simple Inclined Plane, 
262 
Glass Eye, Insertion of, 440 
Gondret's Ointment, 353 
Graduated Compress, 41 
Granville's Lotion, 353 
Groin, Spica of, 95 

Triangular T of, 116 
Gums, lancing of, 428 
Half Maiteese Cross, 39 
Hand, T Bandage of, 117 

Perforated of, 118 
Bleeding in, 336 
Dislocation of, 300 
Handkerchiefs of Head, 144 
Hare-Lip, or Twisted Suture, 

395 
Hartshorne's Splint, 255 
Head, Knotted Bandage for, 104 
Recurrent, 106, 107 
Square cap of, 144 
T Bandage of, 112 
Four-tailed sling of, 128 
Handkerchiefs for, 144 
Dislocations of, 291 
of Humerus, Dislocation 

of, 295 
of Radius, Disl'n of, 309 
Hemorrhage, Arrest of, 344 
from Bladder, 391 
Rectum, 390 
Hernia, 429 
Hip-joint, Dislocation of, 304 

Fracture of, 241 
Hospital Fracture-Box, 269 
Humerus, Neck of, 223 

Dislocations of, 295 
Hutchinson's Splints, 272 
Hyponarthecia, 170 
Immovable Apparatus, 281 
Inclined Plane, 241 
Inhaler Smith's 317 



Injections, use of, 407 

into Rectum, 411 
Urethra, 409 
Vagina, 411 
Lachrymal Ducts. 
407 
Injection of Lungs, 408 
Insertion of Glass Eye, 440 
Instruments of Dressings, 28 
Inter-Femoral Handkerchief, 

156 
Interrupted Suture, 392 
Introduction, 25 
Invaginated Bandages, 120 

for Wounds of lip, 120 
of Body, 121 
Longitudinal Wounds 
of Extremities, 
122 
Transverse, 123 
Wry-neck, 123 
Irrigation, 54 
Isinglass Plaster, 49 
Issue Peas, 354 
Issues, 353 
Jaw, angle of, 85 

Barton's Bandage for, 86 
Crossed Bandage of, 85 
Dislocation of, 291 
Fractures of, 209 
Gibson's Bandage for, 209 
Jorg's Apparatus, 124 
Jugular Vein, Bleeding in, 336 
Junct-Bags, 246 
Knee, Laced Bandage for, 135 
Spiral, Lower Ex- 
tremity of, 80 
Knotted Bandages, 104 

of Head, 104 
Laced Bandages, 135 
Lachrymal Ducts, injection of, 
407 
ts, 

Abscess, 30 

Spring, 332 

Thumb, 333 

Lancing of Gums, 428 

Leeches, Preservation of, 345 

Mechanical, 346 
Leeching, 342 



454 



INDEX. 



Leg, Fractures of ; 269 

Ligatures, 384 

Lint, 31 

Lips, Bandage for Wounds of, 

120 
Lithotomy, 324 
Local Bloodletting, 342 
Lower end of Radius, Fracture 

of, 229 
Lower Jaw, Fractures of, 209 
Dislocations of, 291 
Lungs, Injection of, 408 
Magnum, Dislocation of, 300 
Malteese Cross, 38 
Manufacture of Bandages, 62 
Mask, 130 

Matter from Eyelids, Extrac- 
tion of, 418 
Wounds, 422 
Mayor's Apparatus for Clavi- 
cle, 216 
Clinical Frame, 193 
Hyponarthecia, 170 
Olecranon, 

235 
Patella, 267 
System, 137 
Meigs' Plan of Treating Toe- 
Nail Ulcer, 426 
MembranaTympani, Puncture 

of, 368 
Mental Cravat, 147 
Metacarpal Bones, Fracture of, 
230 
Dislocation 
of, 301 
Metatarsal Bones, 310 
Metatarso-Malleolar Cravat, 
164 
Rotular, 165 
Minor Surgical Operations, 311 
Moxa, 358 

Neck and Axilla, Figure of 8 
Bandage of, 91 
and Brachial Sling of, 195 
of Humerus, 223 
Neck, Sling of, 129 

Uniting of Wounds of, 126 
Wry, 123 
Nose, Fractures of, 208 



Nose, Suspensory of, 133 

T Bandage of, 114 

Nostrils, Plugging of, 389 

Extraction of foreign 
bodies from, 418 
Notch Sciatic, Dislocation into, 

307 
Oblique Processes of Vertebrae, 

292 
Occipito -Auricular Handker- 
chief, 147 
Frontal Handkerchief, 
145 
Occulo-Occipital Triangle, 146 
Olecranon, Fractures of, 231 
Operations, 311 
Operation with Spring Lancet, 
334 
Thumb, 334 
Paracentesis Abdominis, 368 
Paraphymosis, 448 
Parieto-Axillaris Handkerch'f, 

149 
Patella, Fracture of, 265 

Dislocations of, 308 
Penis, bandage of, 75 
Pennsylvania Hospital in Frac- 
ture of Humerus, 225 
of Olecranon, 233 
Pennsylvania Hospital Frac- 
ture-box, 269 
Pelvis, Fracture of, 211 
Perforated Bandage of Hand, 

118 
Perforated Compress, 40 
Perforation of Lobe of Ear, 366 
Pes Equinus, 432 
Petit Tourniquet of, 380 
Phalanges, Dislocation of, 301, 
310 
Fractures of, 231 
Phlebotomy, 328 
Physick's Dressing for Frac- 
ture of Condyles, 225 
Gaiter, 244 
Splints, 250 
Pieces of Dressing 31 
Plasters, 53 



Pledget, 32 



INDEX. 



455 



Plugging of Nostrils, 389 
Porte Caustic, 30 
Posterior 8 of Chest, 87 
Poultices, 51 
Preface, 9 

Preservation of Leeches, 345 
of Vaccine, 365 
Pressure, 377 
Probes, 29 

Processes of Vertebrae, dislo- 
cation of, 292 
Prolapsus Ani, 428 
Pterygium, Excision of, 442 
Pubis, Dislocation on. 307 
Pullies, 299 
Punctures, 361 
Puncture Electro, 363 

of Lobe of Ear, 366 
of Mem. Tympani. 

368 
of Hydrocele, 370 
Purses, 133 

Pyramidal Compress, 41 
Quilled Suture, 396 
Radius, Dislocations of, 298 

Fracture of, 229 
Ranula, 373 
Recurrent of Amputations, 108 

Head, 106, 107 
Reducing Dislocation of Hip, 
Fahnestock's Mode of, 304 
Reduction of Dislocation by 

Pullies, 299 
Retaining Bandage, 66 
Retractors, 39 
Reverses of Bandage, 73 
RibbaiFs Bandage, 101 
Ribs, Dislocations of, 292 

Fractures of, 211 
Roller, Double-headed, 63 
Manufacture of, 62 
Simple, 61 
Single-headed, 63 
Rule for Diagnosis of Injuries 

of Elbow, 299 
Rules for Dressing, 58 
Sailor's Knot, 387 
Salivary Concretions, 374 
Scalpels, 30 
Scapula, 221 



Sciatic Notch, Dislocation into, 

307 
Scissors, 29 

Curved, 29 
Straight, 29 
Scultet's Bandage, 248 
Seton's, 356 
Shaft of Humerus, 224 
Sheaths, 135 

Simple Bis- Axillary Cravat, 151 
Axillo-Scapulary, 
152 
Simple Roller, 61 
Single-headed Roller, 63 
Single Spica, 157 
Skull, Fractures of, 208 
Slings, 127 

of Breast, 131 
Chin, 129 
Face, 130 
Head, 127 
Neck, 129 
Smith, N. R. apparatus, 263 
Smith, H. H. Inhaler, 317 
Spanish Windlass, 379 
Spatula, 30 

Spica Handkerchief, double, 
157 
of Groin, 95 

both Groins, 96 
Instep, 101 
Shoulder, 89 
Thumb, 99 
Spiral Bandage, 70, 74 
Chest, 74 
of Abdomen, 75 
Finger, 77 
all the Fingers, 78 
Penis, 75 

Upper Extremity, 76 
Lower Extremity, 79 
French. 81 
Splint Cloth, 248 
Splints, 249 

Amesbury's, 256 
Boyer's, 253 
Dessault's, 249 
Gibson's Hagedorn, 260 
Hartshorn e's, 255 
Hutchinson's, 272 



456 



INDEX, 



Splints, Nathan R. Smith's, 263 

Physick's, 250 
Sponge Tente, 34 
Spring Lancet, 332 
Starch Bandage, 82, 281 
Sternal Handkerchief, 148 
Sternum, 211 
Stocking-laced, 136 
Stomach, Catheterism of, 403 
Square Cap of Head, 144 
Square Compress, 37 
Sub-Femoral Handkerchief, 

155 
Surgeon's-Knot, 386 
Suspensories, 133 

of Nose, 133 
Scrotum, 134 
Suspensory Handkerchief, 157 
Sutures, 392 

Continued, 394 
Interrupted, 392 
Tailed Bandage, 249 
Tampon, 35 

Tarso-Patella Cravat, 167 
Tarso-Pelvien Cravat, 165 
Tarsus, Bones of, Dislocation. 

309 
T Bandages, 1 1 1 

of Abdomen, 115 
Chest, 115 
Ear, 113 
Head, 112 
Nose. 114 
T doable of Buttock,' 117 
Hand, 117 
of Nose, 114 
Perforated of, 118 
Teeth, Extraction of, 413 
Tente, 33 
Throat, Extraction of Foreign 

Bodies from, 419 
Thumb Lancet, 333, 335 
Tibial Cravat, 169 
Tibio-Cervical Sling, 167 
Toe Nail Ulcer, 425 
Tongue Tie, 427 
Tonsils, Excision of, 446 
Torsion, 388 
Tourniquet of Petit, 380 



Tow, 36 

Transverse wounds of extremi- 
ties, 123 
of'Neck, 124 
Triangle Handkerchief, 144 
Bi-Temporal, 146 
Carpo-Dorsal, 163 
Facial, 147 
Fronto-Occipital. 144 
Occulo-Occipital, 146 
Triangular Cap of Breast, 154 
Amputations, 161 
Foot, 167 
Heel, 164 
Shoulder, 161 
Compress, 38 
T of Groin, 116 
Trough Ante-Brachial, 159 
Twisted or Hare-lip Suture, 395 
Ulcer, Toe-Nail, 425 
Baynton on, 44 
Critchett on, 47 
Uniting Bandage, 65 

of Transverse Wounds 
of Neck, 125 
Upper Extremity, Dislocations 

of, 295 
Urethra, Catheterism of, 398 
Injections into, 409 
Uvula, Excision of, 446 
Vaccination, 363 
Vaccine, Preservation of, 365 
Vagina, Injection into, 411 
Varus, 437 
Venesection, 328 
Veins of Arm, Anatomy of, 328 
Velpeau's Bandage for Acro- 
mion, 221 
Velpeau, use of Adhesive Plas- 
ter, 46 
Vertebrae, Fracture of, 211 

Dislocation of, 266 
Vertico-Mental Cravat, 147 
Wounds, 392 

Wounds, Foreign Matter in, 422 
Windlass, Spanish, 379 
Wrist, Disl'n of Bones of, 300 
Bones of Forearm on, 300 
Fractures of, 229 



THE END. 




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